eHIPAA
Info form
Authorization
Review
Questions?
Call the RareConnections
Support Team
Phone: 1-866-906-6100
Fax: 1-888-863-3361
Hours of Operation:
(Monday–Friday 6 AM- 5 PM
PST / 9AM – 8PM EST)

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About This Form

Thank you for your interest in BioMarin RareConnections. BioMarin RareConnections provides personalized support, including:

  • disease education and management resources;
  • help seeking insurance coverage for therapy;
  • making connections with financial assistance programs.

In order for a BioMarin Representative to contact you and provide you with services, there are some forms you need to sign. They are:

  • Authorization for Disclosure of Protected Health Information by Healthcare Providers and Health Insurers
  • Authorization for Use and Disclosure of Protected Health Information by BioMarin
  • (Optional) Request to Provide Access to Laboratory Reports to BioMarin

Over the following pages, you will

  • Provide identifying information needed to fill out the forms
  • Create an electronic signature to attach to each form
  • Learn why the forms are necessary and how your information will be used
  • Electronically sign the forms if you agree
  • Review the completed forms before signing them
  • Have the option to be sent copies of the signed forms for your records

Please note that, for privacy reasons, you cannot save partially completed, unsigned, forms and go back to them. So please proceed when you have time to complete all the forms, approximately 5-10 minutes.

Patient Information





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Gender *
Gender
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State *
State
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IL
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KS
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LA
ME
MD
MA
MI
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NY
NC
ND
OH
OK
OR
PA
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SC
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VA
WA
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Contact Information



555-555-5555



How did you hear about us?
How did you hear about us?
At a visit to my specialty clinic
At a visit to my primary care physician
On a BioMarin website or social media
At a BioMarin hosted patient/caregiver event
From an email received from BioMarin or other organization
From another person in the Rare Disease Community
From the National PKU Alliance (NPKUA) Back to Care Program