Take advantage of a FREE 30-Day Trial of KUVAN to find out if you respond and if it’s your key to lower Phe!
PATIENT AUTHORIZATION
To share Health Information
(Fields marked * are required)
*Patient Name *Date of Birth
     
Patient’s Guardian Name
Note: Guardian name and electronic signature required if patient is under 18 years of age. *Phone Number
*Address *City
   
*State *Zip *Email
         
Clinic Name Clinician (Doctor/Dietician) Name
Note: If you do not have a doctor or clinic, we will help you find one in your area.
Instructions
For Patient Authorization to Share Health Information for treatment with KUVAN
Instructions
(Please scroll down to accept the terms listed below. In order to accept the Terms of Use, you must check "Yes" inside the scroll box.)
 
For Patient Authorization to Share Health Information for Treatment With KUVAN
BioMarin Pharmaceutical Inc. created BioMarin Patient and Physician Support (BPPS) to help you with case management and to work with your insurance provider to try to help you get coverage, reimbursement, or payment for KUVAN. You will not be charged any money for any BPPS services. BPPS will make every effort to get reimbursement but cannot guarantee that it can find ways to pay for your medicine. You can learn more about these programs by contacting BPPS by phone at 1-877-MY-KUVAN (1-877-695-8826) or by e-mail at bpps@BMRN.com. The BPPS hours of operation are Monday through Friday from 6 AM to 5 PM (PT).
In order to receive help from BPPS, you will need to sign the Authorization. By signing this form, you are allowing BPPS to use your Protected Health Information (PHI) related to elevated blood phenylalanine (Phe) levels to work on your case.
Also, your PHI may be used to contact you about your treatment, opportunities to share your experience with taking KUVAN or to receive periodic information about phenylketonuria (PKU) treatment. Please check the appropriate box(es) on the Authorization based on your wishes, and initial and date this information.
You do not have to sign this form. However, if you choose not to sign this form, a KUVAN representative will not be able to contact you regarding your treatment; BPPS will not be able to provide support for you.
Authorization
What information about me will be disclosed or used?
This Authorization allows my healthcare providers, health plans, and health insurers to give my PHI, including medical records related to elevated blood Phe levels, and financial and insurance coverage information to BPPS. BPPS may share this information in writing or verbally with others as it works on my case. I have the right to see and request corrections to the PHI that is shared with BPPS.
Who is authorized to disclose my PHI?
Healthcare providers, health plans, health insurers, or others who may have my PHI related to my elevated blood Phe levels may share any information connected to getting treatment coverage and medical or other related services.
Who will get my PHI?
The PHI described in this form may be given to and used by BPPS and BioMarin, a biopharmaceutical manufacturer located at 105 Digital Drive, Novato, CA 94949, and its agents, contractors, or assignees. People who work for BioMarin or BPPS may use and see my information, but only for the purpose and terms on this form. All reasonable attempts will be made to keep this information private and confidential, but if it is accidentally shared with others, it may no longer be protected under state and federal privacy laws. BioMarin and BPPS strive to keep all PHI confidential.
How long will my permission last?
This Authorization will last for 10 years after the date that I sign this form. If I change my mind at any time and want to stop sharing my information, I can send BPPS a signed letter that states I do not want my personal information to be shared with BPPS. I understand that if I tell BPPS in writing to stop using my PHI, it will not change any actions BPPS took before I told it to stop. I also understand that if I stop sharing this information, BPPS will not be able to help with my prescriptions for KUVAN, and BPPS will not contact me except to let me know that it received my letter to stop this Authorization.

There is no penalty for choosing not to give my authorization.

I do not have to sign this form. If I choose not to sign this form, BPPS will not be able to provide support to me. If I choose not to share PHI with BPPS, I will not lose any rights or benefits that I may have had before I read this form or made my decision.
How will my PHI be used?
My PHI may be used by BPPS to:
a) help me get coverage, reimbursement, or payment for KUVAN;
b) track the use of KUVAN and provide this information to my healthcare providers upon request;
c) improve BPPS and other BioMarin programs; and
d) contact me about opportunities to share my experience with taking KUVAN.
Click here if you have read and agree to these terms.
Yes, I understand and agree to the terms listed above.
I have read and understand the terms of this Authorization, as outlined below. My questions about the use and disclosure of my Protected Health Information (PHI) have been answered. I knowingly and voluntarily authorize to use and/or disclose my health information as described and agree that an electronic copy or facsimile of this form may be treated as a signed original. I understand that by signing this form I authorize a KUVAN representative to contact me regarding my treatment. I further understand that BioMarin Patient and Physician Support (BPPS) does not in any way promise that it can find ways to pay for medically necessary products and services, and I know that I may have to pay for the costs related to my care.
CHECK THIS BOX TO ELECTRONICALLY SIGN THIS FORM  
This program is offered through BioMarin Pharmaceutical Inc. and is managed by BioMarin Patient & Physician Support (BPPS). If you and your doctor determine KUVAN is right for you, or your child, your FREE 30-day starter supply will be arranged by BPPS.
Before the 30-day trial period ends, you will be evaluated by your clinic to see if you should continue taking KUVAN.
 
Please note the free starter supply of KUVAN is only available in the United States and in clinics that have enrolled to participate; not all US clinics are participating at this time. BioMarin reserves the right to change or discontinue this program at any time. You must be 18 year of age or older to submit this form. A parent or guardian can submit the form on behalf of his/her child. Limit to one free 30-day trial per person with PKU who are trying KUVAN for the first time.

 

Indication

 

KUVAN® (sapropterin dihydrochloride) Tablets is approved to reduce blood Phe levels in patients with hyperphenylalaninemia (HPA) due to tetrahydrobiopterin- (BH4-) responsive Phenylketonuria (PKU). KUVAN is to be used in conjunction with a Phe-restricted diet.

 

Important Safety Information

 

High blood Phe levels are toxic to the brain and can lead to lower intelligence and decrease in the ability to focus, remember and organize information. Any change you make to your diet may impact your blood Phe level. Follow your doctor’s instructions carefully. Your doctor and dietitian will continue to monitor and may adjust your diet throughout your treatment with KUVAN.

 

If you have a fever, or if you are sick, your Phe level may go up. Tell your doctor and dietitian as soon as possible so they can see if they have to adjust your treatment to help keep your blood Phe levels in the desired range.

 

KUVAN is a prescription medicine and should not be taken by people who are allergic to any of its ingredients. Tell your doctor if you have ever had liver or kidney problems, are nursing or pregnant or may become pregnant, have poor nutrition or are anorexic. Your doctor will decide if KUVAN is right for you. Tell your doctor about all the medicines you take.

 

The most common side effects reported when using KUVAN are headache, diarrhea, abdominal pain, upper respiratory tract infection (like a cold), throat pain, vomiting, and nausea.

 

To report SUSPECTED ADVERSE REACTIONS, contact BioMarin Pharmaceutical Inc. at 1-866-906-6100, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

 

Please read the full Patient Information by clicking here.
BIOMARIN