Privacy Notice and Authorization

I authorize healthcare providers, healthcare insurers, and pharmacies that have provided treatment, payment, or services, related to my use of ENBREL, to me or on my behalf (together, "Healthcare Companies") to use my personal health information, including information on insurance coverage and payment for ENBREL, (collectively, "Personal Information"), and/or to disclose my Personal Information to and among Amgen, its contractors, and Healthcare Companies. The Healthcare Companies may receive compensation from Amgen for the use or disclosure of this information.

I authorize Amgen and its contractors to use and/or disclose the Personal Information to (1) provide me with ENBREL informational and marketing materials via SMS, e-mail, direct mail, and/or telephone; (2) help improve, develop, and evaluate products, services, materials, and programs related to my condition or treatment; and (3) enroll me in ENBREL Support™ ("the Program"), which includes reimbursement services, nursing services, the option to join the ENBREL sharps mail-back program to receive sharps disposal containers, and disease management support; and (4) communicate with me via telephone or e-mail referencing ENBREL Support™ I understand Amgen and its contractors will not sell or rent my personal information, but that it may be used, disclosed, and/or transferred to other Amgen locations and/or to Amgen's contractors for the purposes described, or as required by law.

I am aware the ENBREL Privacy Statement is available at www.amgen.com.

My authorization will expire in 10 years or a shorter time period if required by state law, unless I cancel it sooner. I may cancel my authorization by sending a letter to Amgen, PO Box 68376, Indianapolis, IN 46268. Once Amgen receives and processes my cancellation letter, Amgen will not use my personal information going forward. I understand that cancelling my authorization will not affect any use of my information that occurred before my request was processed.

I am entitled to receive a copy of my Authorization and the ENBREL Privacy Statement. Print this page.

By checking the "I Accept" box, I am electronically signing this form (which has the same legal effect as a handwritten signature) and indicating I am at least 18 years old and authorize Amgen and its contractors to use and disclose my Personal Information for the purposes described above.

Please note: If you do not want your Personal Information used for the purposes described above, click the Cancel button to discontinue your registration.