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, specifically aHUS, gMG, HPP, LAL-D, NMOSD and PNH. 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:

Education: Collaborating with your healthcare team to answer questions and provide educational materials related to your disease

Coverage issues and funding options: Assisting patients and practices with insurance coverage questions and research funding options

Management support: Assisting with solutions for balancing all aspects of disease management when faced with major life challenges.

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

Please let us know your role
Please select an indication
Please enter your first name
Please enter your last name
Please enter your address
Please enter your city
Please select your state
Please enter your zip code
Please enter a valid email address
Please enter a valid matching email

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 English | Spanish 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.

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

Get Started
Click here to complete the Enrollment and Authorization Form

We’re
Here
to Help.

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