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Complete this form to access savings on your prescribed EMD Serono Fertility Medications.

Form fields marked with an asterisk (*) are required.

Authorization to Use and Disclose Personal Information (“Authorization”)

My consent is required to process my health and other sensitive data under applicable law and therefore I authorize EMD Serono, Inc., its agents and representatives and any company that assists EMD Serono with its Fertility Instant Savings Program (collectively, “EMD Serono”) to use and disclose any personal information related to my health status, treatment for health conditions, and ability to pay for health treatment (“Personal Information”) that I submit to EMD Serono in connection with EMD Serono’s Fertility Instant Savings Program (the “Program”).

EMD Serono may use and disclose my Personal Information to: (1) contact me by mail, email, text, and/or telephone to enroll me in or administer the Program; (2) provide me with materials relating to the Program; (3) verify the accuracy of the information I provide in my application for the Program; and (4) conduct surveys to measure my satisfaction with the Program.

This Authorization will remain in effect for five (5) years, or such shorter periods as may be required by state law, from the date I check the box below, unless I revoke or withdraw my consent earlier by contacting EMD Serono Fertility LifeLines™ via email (fertilitylifelines@emdserono.com), phone (1-866-LETS-TRY) or in writing (EMD Serono, Fertility Instant Savings Program, 200 Pier 4 Blvd., Boston, MA 02210). If I revoke this Authorization, EMD Serono will stop using and disclosing my Personal Information, as soon as reasonably possible, but the revocation will not affect prior use or disclosure of my Personal Information in reliance on this Authorization. I also understand that I have the right to receive a copy of this Authorization. I understand that, once my Personal Information is disclosed pursuant to this Authorization, it may no longer be protected by federal or state privacy laws and may be subject to redisclosure.

 

Program Terms & Conditions

The Fertility Instant Savings Program is a savings program for the following EMD Serono Fertility medications only: GONAL-F® Multi-Dose or Redi-Ject® (follitropin alfa for injection), Ovidrel® PreFilled Syringe (choriogonadotropin alfa injection), and Cetrotide® (cetrorelix acetate for injection). I understand that EMD Serono reserves the rights to modify, change, or terminate the Program or any services at any time with or without notice. Program participants must be 18 years or older, have a valid prescription for participating EMD Serono Fertility medication(s) for dispensing in the United States, and pay for their participating fertility medication(s) out of pocket, meaning, without seeking reimbursement from any private, commercial, or government health insurance or benefit program. Without limiting the previous sentence, I understand that I may not submit units of Product received under this Program for Medicare, Medicaid, TRICARE, the Department of Veterans Affairs, the Department of Defense, or any public or private third-party reimbursement or return any such units for credit.

I confirm that all financial information (if applicable) is complete and accurate. I understand that EMD Serono, through the Program, may collect relevant financial (e.g., income) and other Personal Information for the purposes of determining my eligibility for the Program, subsequently administering the Program benefits or related services, and as further described in the Authorization.

Use and access of any EMD Serono website is subject to the terms and conditions as set out in EMD Serono Legal Statement and Privacy Policy. I have reviewed the Legal Statement, which sets forth the general terms and conditions for use of the EMD Serono website. I have reviewed the EMD Serono Privacy Policy, which describes how EMD Serono collects, uses and discloses personal information, and my rights with respect to that information. I understand that if I am a California resident I have certain rights with respect to my personal information that are described in the EMD Serono California Consumer Privacy Act Privacy Policy.

Marketing Authorization

I authorize EMD Serono, Inc., its agents and representatives and any company that assists EMD Serono with its Fertility Instant Savings Program (collectively, “EMD Serono”) to use my Personal Information to conduct marketing activities. Which may include but is not limited to: (1) contacting me or providing me with educational or promotional materials, information on EMD Serono products, patient support services, special offers, or services related to my therapy or my medical condition; (2) conducting market research activities, which may include contacting me to participate in focus groups, surveys, or interviews; or (3) use of my Personal Information in a deidentified manner in marketing, educational, or promotional materials. I understand that EMD Serono will not release my Personal Information to any party, except as provided in the Authorization to Use and Disclose Personal Information, this Marketing Authorization, or as permitted by applicable law, without first obtaining my separate written consent. This Marketing Authorization will remain in effect for five (5) years, or such shorter periods as may be required by state law, from the date I check the box below, unless I revoke or withdraw my consent earlier by contacting EMD Serono Fertility LifeLines™ via email (fertilitylifelines@emdserono.com), phone (1-866-LETS-TRY) or in writing (EMD Serono, Fertility Instant Savings Program, 200 Pier 4 Blvd., Boston, MA 02210). If I revoke or withdrawn my consent to this Marketing Authorization, EMD Serono will stop using my Personal Information, as soon as reasonably possible, but the revocation will not affect prior use or disclosure of my Personal Information in reliance on this Marketing Authorization. I also understand that I have the right to receive a copy of this Marketing Authorization.

If you are using insurance or a prescription plan to cover the cost of fertility medications, you are not eligible for this discount.

Eligible patients can apply for additional savings at fertilitysavings.com

If you need help with this form, please call 1-866-LETS-TRY (538-7879)

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Thank you

This is your savings card for your prescribed EMD Serono fertility medications. Please screenshot or download it and share it with a participating pharmacy to receive your discount. The discount is available only at participating pharmacies.

Find a participating pharmacy and learn how to use your discount here.

MEMBER ID XXXX
GROUP XXXX
BIN XXXX
PCN XXXX

Questions? Need help? Please call 1-866-LETS-TRY (538-7879)

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