DISCLAIMERS

This document shall not be construed as a prescription or medical advice. This document or related training is also not meant to provide or replace any medical advice given from the patient’s healthcare provider. Only a patient’s healthcare provider is qualified to provide medical advice to a patient and all questions relating to a patient’s treatment regimen should be directed to the patient’s healthcare provider.

PATIENT INFORMATION

I request that a V-Go Trainer contact me to schedule product training to teach me how to fill, wear and use V-Go.

TO BE COMPLETED BY HEALTHCARE PROVIDER (HCP)

I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge. I authorize MannKind Corporation and any wholly owned subsidiary, subcontractor, assignee, or affiliate entities (collectively, “MannKind”) that operate its patient support hub, as well as its patient onboarding or training of its products, including V-Go to use and disclose the patient information herein contained to the patient’s insurers and pharmacies, to patient training providers, and to obtain information, including protected health information (as defined in 45 CFR § 160.103), from the patient, or from the patient’s insurer or pharmacy, to facilitate dispensing as well as the patient’s enrollment and participation in services offered by MannKind in a manner consistent with the HIPAA minimum necessary standard. I authorize MannKind to contact the patient to report insurance coverage information, to inform the patient about the financial assistance programs offered by MannKind, and to obtain any patient consent(s) that may be necessary to support the patient’s treatment with MannKind as prescribed by me.

Important Safety Information: If regular adjustments or modifications to the basal rate of insulin are required in a 24-hour period, or if the amount of insulin used at meals requires adjustments of less than 2-Unit increments, use of the V-Go Wearable Insulin Delivery device may result in hypoglycemia. The following conditions may occur during insulin therapy with V-Go: hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose). Other adverse reactions associated with V-Go use include skin irritation from the adhesive pad or skin infections at the infusion site. V-Go is magnetic resonance (MR) unsafe and should be removed before having an X-ray, MRI or CT scan.