Slynd Patient
Savings Program

I authorize my healthcare providers, pharmacies, health insurance companies, and each of their respective vendors, representatives, employees, staff, and agents (collectively “Providers”) to use my Protected Health Information (“PHI”) and disclose it to each other and to Exeltis USA and its vendors, representatives, and agents (collectively “Exeltis”) to assist with my obtaining SLYND and participating in the copay card program and to receive marketing communications if I select this option (collectively “Program”). I understand that this PHI may include my contact information (e.g., name, address, phone number, email) and information about my health and care (e.g., relevant medical history, medications, care management, and health insurance).

I understand that information used or disclosed pursuant to this authorization may no longer be protected by certain state or federal privacy laws and may be subject to re-disclosure by Exeltis, including to my Providers. I understand that this authorization is valid for a period of 5 years or shorter, if required by applicable law.

I understand that I may refuse to sign this authorization, and my refusal will not affect the treatment I receive from my Providers, nor will it affect my enrollment or eligibility for health insurance benefits to which I am otherwise entitled. However, if I refuse to sign this authorization, I will not be able to participate in the Program, as the PHI used and disclosed as described in this form is necessary to facilitate my participation in the Program. I also understand that I may revoke this authorization at any time and request a signed copy of this authorization by calling 973-324-0200 or by mailing Exeltis USA, Inc. 180 Park Avenue, Suite 101, Florham Park, NJ 07932. I understand that my revocation will not apply to any information already used or disclosed in reliance on this authorization.