V-Go Cares™ is Here to Support You

I agree to the following:*
- By clicking this button, I authorize my healthcare professionals, including my physicians and pharmacies (“My Providers”), and my health insurance plan (“My Plan”) to use and share my identifiable personal and medical information (such as information about my name, date of birth, diagnosis and treatment) and my identifiable insurance information (collectively, “My Information”) with Zealand Pharma US, Inc., affiliates, representatives, agents, vendors, and other third-party contractors (“Zealand”) so that Zealand can provide me with information, assistance, and support through V-Go Cares (“Patient Support”) as described below; administer and analyze the effectiveness of Patient Support; ask if I am interested in participating in market research; carry out other business purposes related to V-Go®; and comply with law. I understand and agree that my pharmacies may receive payment from Zealand in exchange for sharing My Information with Zealand. Once My Information has been shared with Zealand, federal privacy laws may no longer protect the information. However, Zealand agrees to protect My Information by using and disclosing it only for purposes described in this authorization. I may refuse to sign this authorization and doing so will not affect my treatment, insurance coverage, or eligibility for benefits for which I am otherwise entitled. However, refusing to sign this authorization means that I cannot participate in V-Go Cares. I may cancel or revoke this authorization at any time by mailing a letter to V-Go Cares, 6000 Park Lane, Pittsburgh, PA 15275. If I revoke this authorization, My Providers and My Plan will stop using and sharing My Information, but my revocation will not affect uses and disclosures of My Information made in reliance upon this authorization prior to my revocation. This authorization expires five (5) years from the date signed below, or earlier if required by state or local law, unless I revoke it before then. I will receive a copy of my signed authorization.
*Required.
1. Patient Information
Name*
First Middle Last
Birth Date*
Month
Day
Year
Phone (cell)

One phone number is required.*
Phone (home)
Email
Street Address*
City*
State/Territory*
Zip*
2. Healthcare Provider Information
Name*
First Middle Last
Phone
Fax
City*
State/Territory*
Zip*
V-Go Customer Care may contact the office if additional information is needed or further action required.
3. Primary Insurance - Medical
Please provide accurate information to help expedite your request for support.
Primary Policy Holder's Name
First Middle Last
DOB
Month
Day
Year
Medical Insurance Name
Phone Number
Policy Number
Group Number
4. Primary Insurance - Pharmacy
Please provide accurate information to help expedite your request for support.
Pharmacy Insurance Name
Phone Number
Phone Number
Rx ID
Rx BIN
Rx GRP
Rx PCN
5. Other Insurance Information
(Optional)
I agree to the following:*
- By clicking this button, I agree to allow Zealand Pharma, its affiliates and its agents to collect the information provided and to be contacted by Zealand Pharma, its affiliates, agents, contracted specialty pharmacies, vendors, and other third-party contractors (together, “Zealand”) to collect the information by mail, email, fax, telephone call or text message, including autodialed and prerecorded calls and messages, now and in the future, regarding information about Zealand’s products, services, and other programs or topics of interest, as well as for marketing purposes, to conduct market research or otherwise ask me about my experience with, or thoughts about, such topics. I understand and agree that any information that I provide may be used by Zealand to help develop and improve products, services and programs. I understand that my consent is not required as a condition of purchasing or receiving any goods or services from Zealand. Zealand will not sell, rent or otherwise distribute or transfer your personally identifiable information to any unrelated third party for marketing purposes without your express permission, and will use your information in accordance with its Privacy Policy (https://www.go-vgo.com/privacy-policy). I understand that I may revoke this permission and choose to no longer receive information from Zealand by clicking the “unsubscribe” link provided in the emails I receive from Zealand or by replying “STOP” to SMS messages I receive from Zealand.

V-Go Cares™ is Here to Support You

1. Patient Information

2. Healthcare Provider Information

3. Primary Insurance - Medical

4. Primary Insurance - Pharmacy

5. Other Insurance Information

Indication

Important Safety Information

What is V-Go?

IMPORTANT SAFETY INFORMATION