Enrollment and Authorization Form

OneSource is a patient support program from Alexion that is tailored to the specific needs of people living with rare diseases. When you enroll in the program, you'll work with a dedicated team of OneSource Case Managers who are nurses with expertise in rare disorders and the healthcare system. Your Case Manager is your primary contact with the OneSource program, and is here to help you throughout your journey. When you join OneSource, we may collect information from you or your representative; healthcare providers involved in your treatment; distributors, pharmacies, treatment or infusion sites, or home health agencies that dispense your therapies; and your health insurer, payer, or patient assistance program. At a high level, we will use and disclose such information to coordinate your care, for disease management and patient education, to inform you about studies or meetings that may be of interest to you, to help you understand your insurance benefits and obtain services and funding, to assist with billing and payment, to coordinate distribution of therapy, to fulfill product orders, as required by government agencies, and for other purposes like clinical protocol development. For more details about how we'll use and disclose your information, please see the OneSource Enrollment and Authorization Form English | Spanish.

It only takes a few minutes to enroll. Please complete the following fields:

Please select one of the above

Patient Information

Please select an indication
Please enter First Name (no special characters allowed)
Please enter Last Name (no special characters allowed)
Please enter your address
Please enter your city
Please select your state
Please enter your zip code
Please select Month
Please select Day
Please select Year
Please provide a valid phone number

Please select one of the above
Please select a valid time
Please select AM or PM
Please select time zone
Please enter a valid email address
Please enter a valid matching email
Please provide the name of person authorization release
Please provide the designated representative's relationship to the patient

By clicking "SUBMIT" below, I (or my representative) authorize Alexion to collect, use, store, transfer, and disclose my Personal Information as described in the OneSource Enrollment and Authorization Form and Privacy Notice. This authorization shall remain in effect for ten (10) years unless it is revoked (taken back) by me (or my representative). I (or my representative) understand that I may at any time revoke my enrollment to be contacted for any of these purposes by "opting out" at AlexionOneSource.com.

I understand that I do not have to enroll online and can enroll by downloading the OneSource Enrollment and Authorization Form English | Spanish and mail, email, or fax the form back to us.

Please read and certify by selecting the check box

Get Connected
1.888.765.4747
Or email us at OneSource@alexion.com

Get Started
Click here to complete the Enrollment and Authorization Form

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