Patient or Caregiver Demographics

myAgios-consent.com is a convenient way to submit your consent/authorization to grant you access to myAgios® Patient Support Services. Specifically, myAgios-consent.com allows the patient and/or authorized agent to read specific language regarding access to the product supported by myAgios® Patient Support, acknowledge your understanding of the services offered and easily sign and return your HIPAA consent form online.

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PATIENT AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION (REQUIRED)

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Patient Authorization

I understand that myAgios® Patient Support Services is a service offered by Agios Pharmaceuticals, Inc. to help eligible patients who have been prescribed PYRUKYND® (mitapivat) tablets obtain insurance coverage and financial assistance for PYRUKYND, including through its Coverage Interruption and Patient Assistance Programs (the “Programs”). I give permission for my physician and their staff to disclose my health and other personal information, including, but not limited to the information on this form, to Agios Pharmaceuticals, Inc. and its agents and representatives (collectively “Agios”) so that Agios may use and further disclose my information to healthcare providers, pharmacies, insurance companies, prescription drug plans, and other third-party payers and patient assistance groups (collectively, “Third Parties”) in order to: (1) enroll me in the Programs; (2) facilitate the filling of my prescription for and the delivery and administration of PYRUKYND; (3) assist me in obtaining insurance coverage for PYRUKYND; (4) contact me about PYRUKYND and the Programs (this may include supplemental educational materials, information, offers, and services related to my therapy or my medical condition, or opportunities to participate in focus groups, surveys, or interviews); and (5) manage the Programs. I further authorize the Third Parties to disclose health and other personal information about me in their possession to Agios in order to assist Agios in accomplishing the purposes described above. I understand that once my information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy laws (the Health Insurance Portability and Accountability Act) or state privacy laws and may be further disclosed to others. However, I understand that Agios will not release my information to any party, except as provided in this authorization or as permitted by applicable law, without first obtaining my (or my authorized representative’s) separate written consent. I understand that I may refuse to sign this authorization and such refusal will not affect my ability to receive PYRUKYND that is paid for by my insurer, my treatment, payment for treatment, eligibility for or enrollment in health benefits, but it will limit my ability to receive support services for PYRUKYND, including participation in free medication programs. I understand that this authorization will remain in effect for 3 years, or a shorter period as may be required by state law, from the date of my signature, unless I revoke it earlier by contacting Agios in writing at ConnectMed360 c/o myAgios Patient Support Services, 13410 Eastpoint Centre Drive, Louisville, KY, 40223. If I revoke this authorization, Agios and any Third Parties who are notified of my revocation will stop using and disclosing my information as soon as possible, but the revocation will not affect prior use or disclosure of my information in reliance on this authorization. I understand that the services described in this authorization may be reduced at any time, without prior notification. However, if any services are added, Agios will obtain my authorization to receive any such additional services. I understand that certain Third Parties may receive compensation in exchange for their disclosure of my information to Agios. I also understand that I have the right to receive a copy of this authorization. I verify the information provided is true and correct. If I am the caregiver/representative for the patient, I confirm I am authorized to sign on behalf of the patient.

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Patient Name

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Patient/Representative

Patient Representative

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Representative Name

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Signature of Patient or Representative

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CONSENT TO RECEIVE MATERIAL FROM AGIOS

By enrolling in myAgios Patient Support Services, you consent to receive communications via mail, phone call, email, and text message providing support and educational materials on pyruvate kinase deficiency and PYRUKYND® (mitapivat) tablets as well as communications via mail and email that market Agios products and services. You also have the option to opt-in to receive additional marketing communications via text message related to Agios products or services.

By providing my contact information on this form above, I consent that the information I am providing may be used by Agios and its agents and service providers to keep me informed about Agios products, patient support services, or other opportunities that may be of interest to me via mail and/or email. I acknowledge that I may also receive phone calls, text messages and/or emails containing appointment reminders and other healthcare-related communications. Agios may also combine the information I provide with information about me from third parties to better match information with my interests. You may receive mail or emails that contain information to support and educate on pyruvate kinase deficiency as well as those that market or advertise Agios products or services. Agios understands protecting your personally identifiable information is very important. I understand from time to time, Agios' Online Privacy Policy may change and for the most recent version of the Online Privacy Policy, I should visit myAgios.com/privacypolicy.

Please see Important Safety Information below and accompanying Full Prescribing Information

Please present the following checkbox and statement to your patients as an option for patients to agree to when signing the Patient Authorization form:

By providing my phone number and checking this box, I consent to receive phone calls and text messages, including through the use of an automated telephone dialing system or pre-recorded or artificial voice, from or on behalf of Agios [and its affiliates] that contain information on research opportunities, as well as those that market or advertise Agios products or services at the phone number(s) I provide above. I understand that this consent is not required or a condition of purchasing or obtaining goods or services from Agios..

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