Enroll in My VYVGART Path

Enroll in My VYVGART Path

Patient Self-Enrollment Form
Have you been prescribed VYVGART Hytrulo or VYVGART?*

YesNo
Thank you for your interest. At this time, My VYVGART Path is only available for patients who have been prescribed VYVGART Hytrulo or VYVGART. Please reach out to your doctor about any treatment or healthcare needs.

1. PATIENT INFORMATION
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Patient Email: *
example@example.com
Phone #: *
Alt Phone #
Address*

Street Address

CityState

Zip Code
Patient Gender

MaleFemaleNon-Binary
Patient Preferred Language

EnglishSpanishOther
Please select your condition*

Generalized Myasthenia Gravis (gMG AChR antibody positive)Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
Please select which form of VYVGART you have been prescribed:*

VYVGART (efgartigimod alfa-fcab) for IV infusionVYVGART Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) for subcutaneous injection - Prefilled syringeVYVGART Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) for subcutaneous injection - Vial
Please select which form of VYVGART you have been prescribed:*

VYVGART Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) for subcutaneous injection - Prefilled syringeVYVGART Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) for subcutaneous injection - Vial
2. INSURANCE INFORMATION
Check here if you do not have insurance:

- Or -
Upload your insurance card
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3. PRESCRIBER INFORMATION
Name*

First NameLast Name
Office Phone#:
Practice Information*

Practice Name:

Street Address:

CityState

Zip Code
4. PATIENT AUTHORIZATION TO COLLECT, USE, AND DISCLOSE PROTECTED HEALTH INFORMATION

By signing below, I authorize my healthcare providers, pharmacies, and health plans (collectively, my “Health Team”) to disclose my personal health information (“PHI”), including my medical condition, prescription, and insurance coverage, to argenx, its affiliates, contractors, and agents, in order for them to use and share with my Health Team as needed to enroll me in My VYVGART Path; conduct benefits investigations and take related actions to determine my eligibility, and coordinate financial assistance for me to receive VYVGART Hytrulo or VYVGART; communicate with my Health Team about my treatment plan; provide me with support services, including disease state and VYVGART Hytrulo or VYVGART education and resources; help facilitate prescription and refill fulfillment; facilitate quality control and related reporting activities; use my de-identified data for research and publication; conduct data analytics, market research, and My VYVGART Path–related business activities; and/or contact me about My VYVGART Path services. I understand that once my PHI has been disclosed to argenx, it may no longer be protected by federal privacy law and could be re-disclosed to others; I can withdraw this authorization by calling 1-833-697-2841 or mailing notice of revocation to My VYVGART Path, 680 Century Point, Suite 1000, Lake Mary, FL 32746; revocation will take effect when My VYVGART Path receives my notice of revocation, but uses and disclosures made in reliance on the authorization prior to its revocation will not be invalidated; my healthcare treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits are not conditioned upon my signing this authorization; this authorization expires 10 years after signing or on such earlier date as state law may require; and I am entitled to receive a copy of this authorization after I sign it. A disclosing party may receive remuneration in exchange for PHI if our relationship involves receipt of compensation in exchange for data or in connection with providing PHI pursuant to an authorization. I understand that I am entitled to submit a written request to argenx for a copy of this consent language, along with any disclosed PHI. I further authorize argenx to contact any individual(s) identified as an Authorized Caregiver, below, to discuss my medical condition or my participation in My VYVGART Path, and I understand that such discussions may require argenx to disclose my PHI to such Authorized Caregiver.
Patient Name*
Patient DOB*

MonthDayYear
Patient Signature*

Clear
Date Signed (MM/DD/YYYY)*

MonthDayYear
Date
Authorized Caregiver:

NamePhone
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Please verify that you are human*
Should be Empty:

	Primary Benefit
Insurance Name:
Policyholder Name:
Policy ID#:
Relationship to Patient:
Insurance Provider Phone#:
Group#: