eHIPAA

For questions and Inquiries, please call:
Biogen Biosimilar Support Services
Phone Number: 1-877-422-8360
Fax Number: 1-240-696-8830
Email:
biosimilarsupportservices@biogen.com
Hours of Operations:
8:30 AM - 8:00 PM EST
Monday through Friday

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About This Form

Completing this consent form will allow Biogen to use your personal health information and provide you with support and services.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

Contact Information

Email Address

Patient Cell # *

555-555-5555