Yes, I understand that in order to qualify for the Patient
Program I must meet program requirements. I certify that the
have provided about my household income and size is accurate. I know
myAgiosTM Patient Support Services may ask me for a copy
my recent tax
returns or other proof of income for the purpose of an audit and I
provide such documentation in a timely manner, if requested. I
the information provided above is truthful and accurate to the best
knowledge and that any other information I provide at the Agios'
will be truthful and accurate.
I understand that my eligibility for the program is based on
requirements determined by Agios in its discretion (that
AgiosTM Patient Support Services may change at any time)
that, if approved, I must reapply and continue to meet eligibility
requirements on an ongoing basis. I certify that I will notify the
Patient Assistance Program at 1-844-409-1141 if my income or health
insurance status changes. I agree not to seek reimbursement from
any government program or third-party insurer for any free product
received under the program.
I verify the information provided is true and correct. If I am the
caregiver/representative for the patient, I confirm I am authorized
sign on behalf of the patient.
Representative name (print if applicable)