To participate in UroGen Support offerings, please complete the form below.

UroGen Support is a comprehensive support program dedicated to assisting patients and caregivers with the JELMYTO ® (mitomycin) for pyelocalyceal solution treatment experience. The people at UroGen Support are committed to answering your non-clinical questions, helping to guide patients through the insurance process.

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Patient Authorization

Health Insurance Portability and Accountability Act authorization

I authorize my healthcare providers (including those pharmacies that may receive my prescription for JELMYTO) and my health insurers to disclose personal health information (PHI) about me, including health information relating to my medical condition, treatment, prescription, financial, including results from a soft credit check, insurance coverage, as well as identifying information about me (e.g., name, address, and date of birth) to UroGen Pharma, Ltd., its affiliates, employees, representatives and its agents (collectively "UroGen") that have been hired to administer the UroGen Support program on its behalf in order for UroGen Support to (1) enroll me in UroGen Support; (2) determine my benefit eligibility and potential out-of-pocket costs for JELMYTO; (3) communicate with my healthcare providers and health plans about my treatment plan; (4) provide support offerings including patient education and access to financial assistance for JELMYTO; (5) help get JELMYTO prepared and delivered to my healthcare providers; and (6) facilitate my participation in JELMYTO patient programs that I have elected to receive information about, as indicated below. I agree that, using the contact information I provide, UroGen Support may contact me for reasons related to the UroGen Support program and support offerings and may leave messages for me that may disclose that I am on JELMYTO therapy. I consent to being contacted by a UroGen Support program representative in order for the program to obtain further information or clarification regarding any adverse event I may experience. UroGen may also use PHI about me for quality assurance purposes and to evaluate the operations and services of UroGen Support.

I understand that once my PHI has been diselosed to UroGen Support, it is no longer protected by federal privacy laws and UroGen Support may redisclose it; however, UroGen Support has agreed to protect my PHI by using and disclosing it only for the purposes described above or as required by law

I can withdraw this authorization by calling UroGen Support at 855-535-6986 or mailing a letter requesting such revocation to UroGen Support, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560, but it will not change any actions taken before I withdraw authorization. Withdrawal of authorization will end further uses and disclosures of PHI by the parties identified in this form except to the extent those uses and disclosures have been made in reliance upon my authorization. I understand that I may refuse to sign this form and, if I do so, I will not be able to participate in the UroGen Support program, but it will not affect my eligibility to obtain medical treatment or my ability to seek payment for this treatment or affect my insurance enrollment or eligibility for insurance coverage. Once this form is signed, my prescriber is authorized to send my enrollment to UroGen Support via email, fax, or text message and communicate information via phone in order to facilitate the sharing marketing materials. This authorization expires three (3) years after the date I sign below, or the maximum period allowed under applicable law if less than three years. I understand that I will receive a copy of the signed authorization.

Marketing materials consent

By checking this box, I authorize UroGen Support to send me relevant program and marketing materials that pertain to JELMYTO. This may include materials from UroGen Pharma or a third party working on UroGen Pharma's behalf.

UroGen Support Patient Assistance Program and Commercial Copay Program authorization

By checking this box, I understand that UroGen Support will determine my eligibility for and enroll me in the Patient Assistance Program (PAP) if I am eligible. Generally, patients are eligible for PAP if they have prescribed JELMYTO, do not have insurance coverage for JELMYTO, and have a household adjusted gross income level less than or equal to 400% of the federal poverty level based on their household size.
By checking this box, I understand that UroGen Support will determine my eligibility and enroll me in the Commercial Copay Program if I am commercially insured with a valid prescription for JELMYTO. Enrolled patients will receive a combined maximum annual benefit of $13,800 in total and a maximum benefit of $4,000 per dose. Patient is responsible for $50 per dose, and any remaining costs after any maximum monthly and/or annual benefit is reached. I also certify that information submitted for any affordability program is accurate, that expenses requested for payment are eligible, actually incurred, and that they were not and will not be paid by my insurance, Flexible Spending Account (FSA), Health Savings Account (HSA), Health Reimbursement Account (HRA), or any other payer or discount/copay program. I certify that submitted rebate claims will not be paid by Medicare, Medicaid, Tricare, CHAMPUS, VA, or any other government (state or federally funded) program, and that I am not covered under any of these programs. I understand that I am liable for any misrepresentation herein to the full extent of applicable law. Offer good only in the United States and its territories.

PRIVACY NOTICE For more information on what data we collect about you and how we use it, as well as information about the rights you may have under the California Consumer Privacy Act, please see our Privacy Policy available at www.urogen.com.

If you have questions regarding patient enrollment or require assistance, please call 855-JELMYTO (855-535-6986).

This authorization may be signed electronically. By typing your name at the bottom of this page, you agree that you are signing this document. You understand that your electronic signature is legally binding, just as if you signed a paper document, and you acknowledge that you have read and understand the Patient Authorization.

* I have read and agree to the Patient Authorization

Patient/Parent/Legal Guardian Signature: