Takeda Help At Hand

PO Box 5727, Louisville, KY 40255-0727

Phone: 1-800-830-9159 Fax: 1-800-497-0928

CAN I APPLY?

At Takeda, we believe all patients should have access to the medications prescribed by their healthcare
providers. We also understand that some patients may have financial situations that make it difficult to
pay for their prescriptions. Help at Hand (the Program) provides assistance for people who have no
insurance or who do not have enough insurance and need help getting their Takeda medicines.
All applications are reviewed on a case-by-case basis in accordance with program criteria.
To be eligible, you must:
• Be a resident in the United States
• Not have health coverage, or not have enough coverage to obtain your Takeda
medication
• Have a household income equal to or less than 5 times the Federal Poverty Level (for more
information on Federal Poverty Levels, visit https://aspe.hhs.gov/poverty-guidelines)
• Not have access to alternate sources of coverage or funding
• Have recently lost your job and are experiencing financial hardship

CHECKLIST FOR SUBMITTING APPLICATION

Patients: Providers:
Complete Sections 1 and 2 Complete both sections 3 and 4

Attach current proof of income as Provide the prescriber’s signature at the bottom
outlined in Section 2 of section 4 (signature can NOT be stamped)

Provide patient signatures in Fax or mail the completed application and all
sections 5, 6, and 7 documentation to the address above.

After completing all the information above, fax or mail the application to Help at Hand. NOTE: Failure to
include all the information above will result in the application being placed on hold which
will delay the review of your application.
Once the completed form has been submitted to Help At Hand, it will be reviewed to determine eligibility.
Patients will be contacted via call, text, letter or email (Docusign) for any required information that is missing from
the application. Emailed DocuSign Requests will be received from dse_NA4@docusign.net with an email subject
of “Takeda HAH Documents for Completion Related to Your Application for Patient Assistance.” Patients will
receive a letter explaining if they are eligible.

IMPORTANT: Please go to next page. Call 1-800-830-9159 if you need help.

Help At Hand representatives are available Monday through Friday, 8:00 a.m. to 8:00 p.m. ET

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PLEASE PRINT CLEARLY IN BLACK OR BLUE INK
Red boxes signify required fields

Application type: Initial Renewal

SECTION 1: PATIENT INFORMATION

Patient First Name: Patient Last Name:

Home Address:

City: State: Zip Code:

Cell Phone Number: Email Address:

By checking yes below, I authorize Takeda HAH Patient Assistance Program to send text messages to my cell phone to convey important
information related to my application status or potential shipments. I understand that standard text messaging rates will apply to any
messages received from Takeda HAH Patient Assistance Program. I also understand that I or Takeda HAH Patient Assistance Program
may revoke this permission in writing at anytime. I further agree that in the event that my cellphone phone number changes I will
inform the program. I authorize receiving program communication via text.
Yes No

DOB (MM/DD/YYYY): Gender: Male Female U.S. Resident: Yes No

SECTION 2: INSURANCE AND INCOME

Do you have prescription drug insurance from: (check all that apply)
None VA/Military benefits Health exchange plan Medicare
(if box is checked please enter
Employer supplied/private coverage Medicaid your MBI number below)
MBI#

Number of people in household* *Household = you, spouse and dependents

Total yearly household* income: $

Have you received Social Security Disability Income for at least two years? Yes No

To verify your income, please include a copy of one of the following: Required
Last year’s federal income tax return(s) for yourself, your spouse and your dependents
Social Security Yearly Benefits Statement (SSA-1099) or
All household income statements from the last month
Have you recently lost your job and are experiencing financial hardship? Yes No
If yes, please attach proof of job termination or unemployment.

If these documents do not accurately reflect your current financial status, please send documentation
of your current income.

IMPORTANT: Please go to next page. Call 1-800-830-9159 if you need help.

Help At Hand representatives are available Monday through Friday, 8:00 a.m. to 8:00 p.m. ET

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Red boxes signify required fields

Patient First Name: Patient Last Name: DOB:

SECTION 3: PRESCRIBER INFORMATION

First Name: Last Name: Phone: Fax:

Address: City: State: ZIP Code:

State License Number: NPI #

SECTION 4: PRESCRIPTION INFORMATION (NJ and NY physicians please attach appropriate prescription)

Allergies: No Known Allergies

Health Conditions: None

Current Medications: None

Product (Please select and complete ship product to below) Strength Directions Quantity Refills (please select)

CARBATROL® (carbamazepine) Extended-Release Capsules mg 90-days 1 2 3

DEXILANT® (dexlansoprazole) Delayed Release Capsules mg 90-days 1 2 3

EOHILIA™ (budesonide oral suspension) 2 mg/10 mL 90-days 1 2 3

FOSRENOL® (lanthanum carbonate) Chewable Tablets mg 90-days 1 2 3

FOSRENOL® (lanthanum carbonate) Oral Powder mg 90-days 1 2 3

INTUNIV® (guanfacine) Extended-Release Tablets mg 90-days 1 2 3

LIALDA® (mesalamine) Delayed-Release Tablets 1.2 gm 90-days 1 2 3

MOTEGRITY® (prucalopride) Tablets mg 90-days 1 2 3

PENTASA® (mesalamine) Extended-Release Capsules mg 90-days 1 2 3

PREVACID SOLUTAB® (lansoprazole) Delayed-Release Orally mg 90-days 1 2 3

Disintegrating Tablets

ROZEREM® (ramelteon) Tablets 8 mg 90-days 1 2 3

TRINTELLIX® (vortioxetine) Tablets mg 90-days 1 2 3

Ship Product to Physician’s Office Patient’s Address (If no selection is made, product will be shipped to Patient’s Address)

CARBATROL, DEXILANT, EOHILIA, FOSRENOL, INTUNIV, LIALDA, MOTEGRITY, PENTASA, PREVACID SOLUTAB, ROZEREM, TAKEDA, the TAKEDA logo
and TRINTELLIX are trademarks or registered trademarks of Takeda Pharmaceutical Company Limited or its subsidiaries and affiliated companies.
My signature certifies that prescribed therapy is medically necessary for the subject patient and that I will be supervising the patient’s treatments. I certify that the
information provided by me on this application is true and accurate.
I certify that my signature encompasses any other doctor in my practice/organization. I certify that there will be no charge back cost to the patient above.
Additionally, I certify that if the product is sent to my office on behalf of the patient, I understand that it must be used for the patient listed on this application, and not
to be resold or offered for sale or trade, nor shall the patient nor any third-party payer, Medicare or Medicaid be charged for this product.

Prescriber Signature (Stamped Signatures NOT ACCEPTED)

SIGN
X Date:

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Patient First Name: Patient Last Name: DOB:

SECTION 5: PATIENT DECLARATIONS PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW

1. The information provided by me on this application form is true and accurate;

2. I give consent to the Program to disclose my enrollment in the Program as needed to comply with legal and regulatory
obligations;
3. I agree to notify the Program immediately, in writing, if my prescription drug coverage changes in any way or if I
discontinue use of the requested medication;
4. I will not seek or accept reimbursement from any health or prescription coverage plan, including a Medicare plan, for
medication received from the Program;
5. I understand that if I am eligible or enrolled in a Medicare plan, I will
a. receive the requested medication from the Program for the remainder of the enrollment calendar year for which my
application was approved, and I will not seek the requested medication from my Medicare plan for the remainder of
the enrollment calendar year;
b. not seek true out-of-pocket (TrOOP) credit for any medication received from the Program because I understand that
medication received from the Program will not count toward my TrOOP; and
c. agree to notify my Medicare plan that I will receive my Takeda medication for free until the end of the year through
the Program;
6. I want Takeda Help at Hand Patient Assistance Program (“PAP”) to conduct e-income verification which will include
a soft credit check to determine household income. I understand that I am hereby providing “written instructions,”
under the Fair Credit Reporting Act (FCRA), authorizing the PAP and its vendors to run a soft credit check or
other information about me from (the vendor) for the purpose of determining my financial eligibility for the PAP.
I understand that I must affirmatively agree to these terms in order to proceed in this financial screening process
for the PAP. I also understand that I may need to provide additional documentation and that additional eligibility
requirements apply for the PAP.

Patient Signature/Legal Representative (indicate relationship)

The parties agree that this Amendment may be executed and delivered by electronic signatures and that the signatures appearing on
this Amendment are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

SIGN X Date:

If signature is of legal representative:

Legal Representative Name: Relationship to Patient:

Takeda does not charge patients a fee for its assistance. Takeda is not affiliated with third parties who charge a fee for
assistance with enrollment or medication refills. If you are being charged a monthly fee for support from Takeda, the
organization billing you is not Takeda and you are being charged for support that Takeda can provide to you directly at no cost.

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Patient First Name: Patient Last Name: DOB:

SECTION 6: PATIENT AUTHORIZATION PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW

By signing the Patient Authorization section of this Help At Hand Patient Assistance Program form, I authorize my
physician, health insurance, and pharmacy providers (including any specialty pharmacy that receives my prescription)
to disclose my protected health information, including, but not limited to, information relating to my medical condition,
treatment, care management, and health insurance, as well as all information provided on this form (“Protected Health
Information”), to Takeda Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the affiliates and service
providers that work on Takeda’s behalf in connection with the Help At Hand Patient Assistance Program (the “Companies”).
The Companies will use my Protected Health Information for the purpose of facilitating the provision of the Help At Hand
Patient Assistance Program, supplies, or services as selected by me or my physician and may include (but not be limited
to) verification of insurance benefits and drug coverage, prior authorization education, financial assistance with co-pays,
patient assistance programs, and other related programs. Specifically, I authorize the Companies to 1) receive, use, and
disclose my Protected Health Information in order to enroll me in the Help At Hand Patient Assistance Program and contact
me, and/or the person legally authorized to sign on my behalf, about the Help At Hand Patient Assistance Program; 2)
provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and
services related to the Help At Hand Patient Assistance Program; 3) verify, investigate, and provide information about my
coverage for the Help At Hand Patient Assistance Program, including but not limited to communicating with my insurer,
specialty pharmacies, and others involved in processing my pharmacy claims to verify my coverage; 4) coordinate
prescription fulfillment; and 5) use my information to conduct internal analyses.
I understand that employees of the Companies only use my Protected Health Information for the purposes described
herein, to administer the Help At Hand Patient Assistance Program or as otherwise required or allowed under the law,
unless information that specifically identifies me is removed. Further, I understand that my physician, health insurance,
and pharmacy providers may receive financial remuneration from the Companies for providing Protected Health
Information, which may be used for marketing purposes. I understand that Protected Health Information disclosed under
this Authorization may no longer be protected by federal privacy law. I understand that I am entitled to a copy of this
Authorization. I understand that I may revoke this Authorization at any time and that instructions for doing so are contained
in Takeda’s Website Privacy Notice available at www.takeda.com/privacy-notice/, or I may revoke this Authorization
at any time by sending written notice of revocation to the Help At Hand Patient Assistance Program at PO Box 5727,
Louisville, KY 40255-0727. I understand that such revocation will not apply to any information already used or disclosed
through this Authorization. This Authorization will expire at the earliest of what is required by state law, and never in any
case longer than 5 years. I also understand that if I do not sign this Authorization, I will not be able to receive Help At
Hand Patient Assistance Program products, supplies, or services.

Patient Signature/Legal Representative (indicate relationship)

SIGN X Date:

If signature is of legal representative:

Legal Representative Name: Relationship to Patient:

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Patient First Name: Patient Last Name: DOB:

SECTION 7: TEXT MESSAGE COMMUNICATIONS PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW

By agreeing to these Help at Hand Patient Assistance Program (the “Program”) text message terms and conditions, you agree to receive text
messages on your mobile device subject to the Terms & Conditions described below. You also consent to receive autodialed and/or pre-
recorded calls and/or text messages from or on behalf of the Program at the telephone number provided above. You understand that this
consent is not a condition of purchase or use of the Program or of any Takeda product or service. You can unsubscribe from receiving text
messages by texting STOP. You will remain enrolled in the Help at Hand Patient Assistance Program. For questions about this Program, text
HELP or contact the customer support center at 1-800-830-9159.
Participants will receive an average of 5 text messages each month while enrolled in the Program. Such messages may be nonmarketing
messages related to the Patient Assistance Program.
There is no fee payable to Takeda to receive text messages; however, your carrier’s message and data rates may apply.
You represent that you are the account holder for the mobile telephone number(s) that you provide to opt into the Program. You are
responsible for notifying Takeda immediately if you change your mobile telephone number. You may notify Takeda of a number change by
calling 1-800-830-9159.
Data obtained from you in connection with your registration for, and use of, this SMS service may include your phone number and/or email
address, related carrier information, and elements of pharmacy claim information and will be used to administer this Program and to provide
Program benefits such as information about your prescription, refill reminders, as well as Program updates and alerts.
Takeda will not be liable for any delays in the receipt of any SMS messages as delivery is subject to effective transmission from your network
operator.
This Program is valid with most major U.S. carriers, including Verizon Wireless, Sprint, Nextel, Boost Mobile, T-Mobile®, AT&T, Alltel, ACS
Wireless, Bluegrass Cellular, Carolina West Wireless, CellCom, Cellular One of East Central Illinois (ECIT), Cincinnati Bell, Cricket, C-Spire
Wireless, Duet IP (aka Max/Benton/Albany), Element Mobile, Epic Touch, GCI Communications, Golden State, Hawkeye (Chat Mobility),
Hawkeye (NW Missouri Cellular), Illinois Valley Cellular (IVC), Inland Cellular, iWireless, Keystone Wireless (Immis/PC Management),
MetroPCS, MobiPCS, Mosaic, MTPCS/ Cellular One (Cellone Nation), Nex-Tech Wireless, nTelos, Panhandle Telecommunications, Pioneer,
Plateau, Revol Wireless, Rina-Custer, Rina-All West, Rina-Cambridge Telecom Coop, Rina-Eagle Valley Comm, Rina-Farmers Mutual Telephone
Co, Rina-Nucla Nutria Telephone Co, Rina-Silver Star, Rina-South Central Comm, Rina-Syringa, Rina-UBET, Rina-Manti, Simmetry, South
Canaan/CellularOne of NEPA, Thumb Cellular, Union Wireless, United Wireless, U.S. Cellular, Viaero Wireless, Virgin Mobile, and West
Central Wireless (includes Five Start Wireless).

Patient Signature/Legal Representative (indicate relationship)

SIGN X Date:

If signature is of legal representative:

Legal Representative Name: Relationship to Patient:

What happens next? You and/or your healthcare provider will receive an answer from Takeda Help At Hand within five to seven days
after we receive your application. Please call 1-800-830-9159 if you have questions. Representatives are available Monday
through Friday from 8:00 a.m. to 8:00 p.m. ET. Quantity of bottles supplied may vary based on patient prescription.
This program, as well as all Takeda Pharmaceuticals U.S.A., Inc. programs, can be discontinued or changed at any
time without notice at the discretion of Takeda Pharmaceuticals America, Inc.

Takeda Help At Hand

PO Box 5727, Louisville, KY 40255-0727
Phone: 1-800-830-9159 Fax: 1-800-497-0928

Help At Hand and the associated logo are trademarks or registered trademarks of Takeda Pharmaceuticals U.S.A., Inc. TAKEDA and the
TAKEDA logo are registered trademarks of Takeda Pharmaceutical Company Limited. © 2023 Takeda Pharmaceutical Company Limited.
All rights reserved. US-XMP-2628v3.0 08/24