How to initiate enrollment for your patient into my bluebird support

• Please complete all required fields to initiate enrollment for your patient into my bluebird support and return via fax to my

bluebird support at 1-844-999-6378.

Fields with an * are required information to initiate enrollment.

Program Enrollment Form for Referring Physicians

Phone: 1-833-888-6378 • Fax: 1-844-999-6378 • Email: m[email protected]

•

I certify that the personal information that I provide to my bluebird support, the support program from bluebird bio, Inc., is true and complete.

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I certify that all plans and programs through which I obtain healthcare coverage are listed above. I further certify I am a resident of the United States

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I understand that changes in my insurance provider, insurance coverage, or financial situation may affect my eligibility for certain my bluebird support program services and I

agree to immediately notify my Patient Navigator at 1-833-888-6378 if any of these change (i.e., if I start to receive benefits from a federal or state government funded

program, such as Medicare or Medicaid)

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I understand that enrollment in my bluebird support is not required in order to access a bluebird gene therapy

•

I acknowledge and agree to these terms and conditions of my bluebird support

•

I understand that bluebird bio does not guarantee coverage or reimbursement for applicable products. Coverage and reimbursement decisions are made by insurance

companies following the receipt of claims

Date (MM/DD/YYYY)

Signature of Patient or Legal Representative (if patient is under 18 Years of Age)

†

Print Name of Patient or Legal Representative (if patient is under 18 Years of Age)

Relationship to Patient

†

By signing on behalf of the patient, as representative or guardian, I attest that I am legally authorized to sign such documents on the patient’s behalf and am properly acting in my capacity

in doing so. Proof of such guardian’s or representative’s authority to act for the patient (such as power of attorney or legal court order) may be requested.

For questions, call my bluebird support at 1-833-888-6378

or email [email protected]

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Policyholder DOB*

Policy Number*

Group Number

Policyholder Name*

Relationship to Policyholder*

Policyholder Name

Policyholder DOB

Policy Number

Primary Insurance*

Phone Number*

Secondary Insurance

hone Number

Relationship to Policyholder

Group Number

First Name*

I certify to the following: (a) I have obtained the patient's authorization for the disclosure of the patient’s information on this form to bluebird bio, Inc. and its agents (collectively “bbb”), for purposes of benefits verification,

to assess the patient's eligibility for participation in my bluebird support, and for coordination in assessing the patient for eligibility for therapy; (b) I allow bbb to utilize my information provided in this enrollment form,

including NPI/Tax ID, for the purpose of conducting the patient's benefits verification (c) I understand that I am under no obligation to recommend any bluebird bio product and I have not received and will not receive any

benefit from bluebird bio for recommending a bluebird bio product; (d) the information contained in this form is accurate to the best of my knowledge; (e) I understand bluebird bio does not guarantee assistance and

reserves the right to revise or cancel programs at any time; (f)

I have reviewed and understand bluebird bio's Privacy Policy.

PATIENT SECTION MAY BE COMPLETED BY PATIENT IF PRESENT DURING TIME OF SUBMISSION

If patient is not present and the following sections of this form cannot be completed at submission, my bluebird support will reach out directly to the patient to complete enrollment. If

patient is under the age of 18, the patient's legal representative should fill out patient sections of the form.

Preferred Method of Contact _ Phone _ Email _ Text

OPT-IN TO RECEIVE my bluebird support TEXT MESSAGES (Optional)

By checking this box, I acknowledge that I have read bluebird bio’s Privacy Policy (https://www.bluebirdbio.com/privacy-policy) and my bluebird support's texting Terms of Service

(https://mybluebirdsupport.com/text-terms-of-service). I have read the Opt-in information below and by checking the box hereby provide my consent to receive support program

text messages from my bluebird support at the telephone number(s) I provided. I understand that I am not required to provide this consent as a conditi on of purchasing or

receiving an y goods or serv ices from bluebird bio. I may text “STOP” to opt out at any time. I may text “HELP“ for h elp at any time. I understand

message and data rates m ay apply. Message fr equency varies. If I have any quest ions about my text plan or data plan, I must contact my wireless provider.

Last Name*

City*

Fax*

Address*

Phone*

DEA Registration Number*

Treatment Name*

Office Contact Name*

State*

Physician Practice Name*

Zip Code*

NPI Number*

Date (MM/DD/YYYY)*

Email*

Healthcare Provider Signature*

Tax ID Number*

imary Diagnosis/ICD-10-CM Code

Phone Number* Email*

________________________________________________

Last* ______________________________________________________________

Gender* _ Male _ Female Preferred Language (if not English)

Patient Name

First*

Zip Code*

Date of Birth (MM/DD/YYYY)*

Address*

Phone*

City* State*

Email Address*

Caregiver Name (required if patient is <18 years old)____________________________________ Relationship to Patient ________________________

Qualified Treatment Center Name (if known) ______________________________________________________________________________________

PATIENT INFORMATION

ENROLLING PHYSICIAN INFORMATION

CONTACT OPT-IN TO BE COMPLETED BY PATIENT/CAREGIVER (OPTIONAL)

PATIENT/CAREGIVER CERTIFICATION - ALL FIELDS BELOW TO BE COMPLETED BY PATIENT (OPTIONAL)

INSURANCE INFORMATION

Please include a copy of the front and back of all of the patient's insurance card(s), if available.

Healthcare Provider Name* ______________________________________________________________

Program Enrollment Form for Referring Physicians

Phone: 1-833-888-6378 • Fax: 1-844-999-6378

Signature of Patient or Legal Representative (if patient is under 18 Years of Age)

†

Print Name of Patient or Legal Representative (if patient is under 18 Years of Age)

Date (MM/DD/YYYY)

Relationship to Patient

For questions, call my bluebird support at 1-833-888-6378

Signature of Patient or Legal Representative (if patient is under 18 Years of A

ge)

†

Date (MM/DD/YYYY)*

Print Name of Patient or Legal Representative (if pati

ent is under 18 Years of Age)

Relationship to Patient

†

By signing on behalf of the patient, as representative or guardian, I attest that I am legally authorized to

sign such documents on the patient’s behalf and am properly acting in my capacity in doing so. Proof of

such guardian’s or representative’s authority to act for the patient (such as power of attorney or legal

court order) may be requested.

• I consent to receiving communications by mail, email, or telephone (if I authorized) about bluebird bio products, services, and programs or other topics of interest. I

authorize bluebird bio to contact me to conduct market research or otherwise ask me about me or my loved one's experience with or thoughts about such topics. I

understand and agree that any information that I provide may be used by bluebird bio to help develop new products, services, and programs

• I understand that this Consent to Receive Marketing and Promotional Communications is not required to enroll in my bluebird support and is not required as a

condition of purchasing any goods or services

• I understand that bluebird bio will not sell or transfer my personal data to any unrelated third party for marketing purposes without my express permission

• I have reviewed and understand bluebird bio’s Privacy Policy

• I may opt out of marketing-related emails by clicking the “Unsubscribe” link at the bottom of each such email. To stop receiving other communications from bluebird

bio, please contact us at [email protected] with your request

• This marketing consent expires after ten (10) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my

signature unless otherwise canceled earlier as set forth above

• I understand I will receive a copy of this form after completing enrollment

Patient/Caregiver Consent to Receive Marketing and Promotional Communications (optional)

†

By signing on behalf of the patient, as representative or guardian, I attest that I am legally authorized to sign such documents on the patient’s behalf and am properly acting in my capacity

in doing so. Proof of such guardian’s or representative’s authority to act for the patient (such as power of attorney or legal court order) may be requested.

bluebird bio, the bluebird bio logo, and the my bluebird support logo are trademarks of

3 08/23

AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION

I authorize and request that my treating physicians, health insurance plan(s), pharmacies or other health care

providers (collectively “Health Care Providers”) disclose my protected health information including medical,

laboratory, and/or pharmacy records related to my diagnosis of, eligibility for therapy to treat and treatment

of my medical condition relevant to a bluebird bio gene therapy, and other social determinants of health to

bluebird bio and its affiliates (collectively “bluebird”), its contractors and business partners. This authorization

is made for the purpose of enrolling me in bluebird’s patient services program, providing me with patient

services, and administering the patient services program. I understand that bluebird bio, its contractors and

business partners may use and disclose my protected health information for the activities described in this

authorization, including but not limited to communicating with my Health Care Providers to administer bluebird

bio's Patient Services programs.

I understand that I have the right to revoke this authorization, in writing, at any time, except where

disclosures have already been made based upon my original authorization. This authorization shall remain

valid for a period of ten (10) years from the date the Authorization is signed, unless a shorter period is

provided for by state law or revoked in writing prior to that time. I understand that I need to send a written

request to revoke my authorization to a designated person/office at the specific Health Care Provider(s) or

Insurers who provide information to bluebird bio.

I understand that it is possible that information used or disclosed with my permission pursuant to this

Authorization may be re-disclosed by the recipient and may no longer be protected by federal or state law.

I understand that signing this authorization is voluntary. My treatment, payment, or eligibility for benefits is not

conditioned upon my authorization of this disclosure. I acknowledge, however, that if I do not sign this

authorization, I will not be able to participate in bluebird patient services programs.

I understand that certain parties, such as my pharmacy provider, may receive remuneration (payment) from

bluebird bio in connection with the activities described in this authorization.

I understand I will receive a copy of this authorization upon completion of enrollment.

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