eHIPAA
Info form
Authorization
Review
Questions?
Call the Xembify® Connexions Program
Phone: 1-844-MYXEMBIFY
(1-844-699-3624)
Fax: 877-375-0758
Hours of Operation:
(Monday–Friday 8 AM- 8 PM EST)
Please see
Important Safety Information and
Full Prescribing Information

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About This Form

You have expressed an interest in Xembify® Connexions Program. The Xembify® Connexions Program can provide certain offerings to you and on your behalf during the search for reimbursement, and during your therapy. The Xembify® Connexions Program is an agent of Grifols. In order to provide these Services, Grifols will need to use your health information (called “Protected Health Information” or “PHI”), and to share it with your health plan and the pharmacy that will receive your doctor’s prescription. This authorization will allow your healthcare providers, health plans, and health insurers that maintain PHI about you to disclose your PHI to Grifols so that the Xembify® Connexions Program may provide these Services to you, or on your behalf.

Patient Information





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Contact Information



555-555-5555



Questions?
Call the Xembify® Connexions Program
Phone: 1-844-MYXEMBIFY
(1-844-699-3624)
Fax: 877-375-0758
Hours of Operation:
(Monday–Friday 8 AM- 8 PM EST)
Please see
Important Safety Information and
Full Prescribing Information