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paid for or reimbursed, in whole or in part, by any federal, state or government-funded healthcare program and you must have prescription drug coverage with a commercial or private healthcare insurance carrier to be eligible for this program.If at any time you begin receiving prescription drug coverage under any such federal, state or government-funded healthcare program, you will no longer be eligible to participate in the ENBREL Support™ Co-pay Card and you may no longer use this card. (You must agree in order to be eligible.) Based on the information you gave us, you are not eligible for the ENBREL Support™ Co-pay Card.

Please talk to your doctor if you have questions about your medical care or treatment.I understand that I can obtain a copy of this Authorization or cancel this Authorization at any time by calling Amgen at 1-888-4ENBREL (1-888-436-2735) or by writing to PO Box 7249, Bedminster, NJ 07921.If I cancel my consent, I will no longer qualify for the services described.adherence programs) and other patient support services.Expiration, Right to Obtain a Copy and Right to Cancel I understand that by signing this form, I authorize my Health Care Providers or others who might hold my health information to only release it to Amgen employees, as well as to its contractors and business partners, who are performing the services set forth in this Authorization.

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