LEMTRADA REMS Patient Enrollment and Prescription Ordering Form

*INDICATES A MANDATORY FIELD. PLEASE PRINT.

INSTRUCTIONS FOR PRESCRIBERS:

To enroll a new patient in the LEMTRADA REMS, complete all sections below (A through F). Patient must

complete sections D and E.

To submit a prescription order for LEMTRADA for a patient already enrolled in the LEMTRADA REMS,

complete sections A (must indicate patient is REMS enrolled and provide the REMS ID), B and C.

Please submit this form online at www.lemtradarems.com or fax this completed form to the LEMTRADA

REMS at 1-855-557-2478.

This form must be completed before you can receive LEMTRADA. Your prescriber will help you complete this form

and will give you a copy.

Patient already enrolled in LEMTRADA REMS

LEMTRADA REMS Identification Number (if already enrolled)

Name (Last, First)* Date of Birth (MM/DD/YYYY)*

Street Address* City* State* ZIP Code*

Phone Number*

Gender*

Male Female Neutral Prefer not to say

Secondary Contact Name (Last, First) Phone Number

Prescriber Name (Last, First)* NPI Number* Phone Number*

FOR PRESCRIBERS & PATIENTS

SECTION A: PATIENT INFORMATION

PRESCRIBER INFORMATION

‡

Note: LEMTRADA can only be infused at REMS Certified infusion sites. Sanofi Genzyme will contact you if the infusion center you have indicated is not certified to

infuse LEMTRADA.

Infusion Center Where Patient Is Referred* Phone Number*

Street Address* City* State* ZIP Code*

Ship to a Different Address

Street Address* City* State* ZIP Code*

†

Note: Provision of the patient's insurance coverage(s) is not a requirement of the LEMTRADA REMS, but may support additional services provided by

Sanofi Genzyme.

INSURANCE INFORMATION

†

Patient does not have insurance.

Prescriber Name (Last, First)* NPI Number* Name of Institution or Facility* Tax

Office Contact* Street Address* City* State* ZIP Code*

Email Address Phone Number* Fax Number*

Primary Insurance Company Phone Number Name of Insured Policy Number Group/Policy Number

Secondary Insurance Company Phone Number Name of Insured Policy Number Group/Policy Number

Primary diagnosis: ICD-9 CM340

ICD-10 G35

LEMTRADA

12 mg IV (Check one*)

Initial course (1 vial [12 mg/day]) X 5 consecutive days Total number of vials ordered:

Subsequent course (1 vial [12 mg/day]) X 3 consecutive days Total number of vials ordered:

FOR PRESCRIBERS & PATIENTS

SECTION B: THIS SECTION SHOULD BE FILLED OUT BY THE PRESCRIBER

PRESCRIBER INFORMATION

SECTION C: INFUSION CENTER INFORMATION

‡

If you have any questions regarding the LEMTRADA REMS, call 1-855-676-6326.

SECTION F: PRESCRIBER SIGNATURE

Licensed Prescriber Signature* (Signature required; no stamps accepted) Date*

Print Name*

I acknowledge that I have explained the LEMTRADA REMS to this patient. By signing below, I authorize the LEMTRADA REMS and its

agents and representatives to forward this prescription on my behalf to a certified pharmacy or infusion center to dispense

LEMTRADA to the patient named above.

Note to Prescribers: This form does not authorize the certified pharmacy or infusion center to dispense LEMTRADA. The LEMTRADA

REMS Patient-Authorization and Baseline Lab Form must be submitted in order to authorize LEMTRADA to be dispensed.

Please submit this form online at www.lemtradarems.com or fax this completed form to the LEMTRADA REMS at 1-855-557-2478.

SECTION E: PATIENT SIGNATURE

Patient/Legal Representative Signature* Relationship to Patient*

Print Name* Date*

• I have received, read, and understand the LEMTRADA Treatment

and Infusion Reactions Patient Guide that my doctor has given

to me.

• My doctor has reviewed with me the benefits and risks of treatment

with LEMTRADA.

• I am aware that LEMTRADA is associated with serious risks,

including autoimmune conditions, infusion reactions, stroke and

malignancies, and that these complications can be identified

through periodic monitoring and awareness of the initial signs and

symptoms.

— I understand the need to have blood and urine tests within

30 days prior to my first LEMTRADA treatment, then each

month for 4 years following my last treatment with LEMTRADA.

— I understand the need to have thyroid testing within 30 days

prior to my first LEMTRADA treatment, then every 3 months for

4 years following my last treatment with LEMTRADA.

— I understand the need to have yearly skin exams prior to my

first LEMTRADA treatment, and continuing for 4 years following

my last treatment with LEMTRADA.

— I will tell my doctor if I have any reactions or symptoms after

receiving LEMTRADA.

• I understand that I must tell all of my doctors that I have received

LEMTRADA.

• I understand that in order to receive LEMTRADA, I am required to

enroll in the LEMTRADA REMS and my information will be stored

in a secure and confidential database of all patients who receive

LEMTRADA in the United States. After enrolling, my doctor will

provide me with a signed copy of the enrollment form.

• My doctor has counseled and provided me with a LEMTRADA

Patient Safety Information Card, which I should carry with me at all

times in case of an emergency.

• I understand that I must tell Genzyme if I change my doctor.

• I understand that I must tell Genzyme if my contact information

changes.

• I give permission to Genzyme and its agents to use and share

my personal health information for the purposes of enrolling

me into the LEMTRADA REMS, coordinating the dispensing of

receiving LEMTRADA, administering the LEMTRADA REMS, and

releasing my personal health information to the Food and Drug

Administration (FDA) as necessary.

• By completing the information below, I understand Genzyme and

its agents will contact me or my prescriber by phone, mail,

or email to support administration of the LEMTRADA REMS.

I prefer to be contacted:

By mail By phone

By email (email required to provide digital signature)

SECTION D: PATIENT AGREEMENT

By signing this form, I acknowledge that:

Lemtrada and Sanofi are registered in U.S. Patent and Trademark Office.

US.MS.LEM.14.10.007-v6-07/2022

FOR PRESCRIBERS & PATIENTS