Welcome to CareZ enrollment

Please provide your CareZ preferences to help personalize your experience

By providing consent, I am choosing to receive marketing materials, requests to participate in company-sponsered program, and/or new patient resources from CSL Behring and its affiliates.

By signing this Authorization, I authorize my health plans, physicians, and pharmacy providers to disclose my personal health information, including, but not limited to, information relating to my medical condition, treatment, care management and health insurance, as well as all information provided on this form and any prescription (“Protected Health Information”), to Sonexus Health—and its representatives, agents, and contractors for the following purposes: (1) to establish my eligibility for benefits; (2) evaluation and enrollment in one or more financial assistance program(s), such as a co-pay mitigation program and/or patient assistance programs (if one or more of such programs apply to my treatment with ZEMAIRA); (3) enrollment in available patient services programs; (4) to communicate with my healthcare providers and me about my medical care; (5) to facilitate the provision of products, supplies, or services by a third party including, but not limited to specialty pharmacies; (6) to register me in any applicable product registration program required for my treatment; and (7) to contact me with educational or treatment support materials and requests for participation in patient programs related to treatment. This authorization expires five (5) years from the date signed below, or earlier, if required by state law.

I understand that I may refuse to sign this Authorization and that my treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this Authorization. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization at any time by mailing a letter requesting such cancellation to ZEMAIRA CareZ Program, c/o PO Box 368 Lewisville, TX 75067, but that this cancellation will not apply to any information already used or disclosed through this Authorization.