1. PATIENT INFORMATION - …
© 2018 Sanofi US Services, Inc. SAUS.SA.18.03.1439 P.O P: 1.888.847.4877 · F: 1.888.847.1797 . Box 222138 · Charlotte, NC 28222-2138 APPLICATION
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www.sanofipatientconnection.comrelated to my medical condition, treatment, health insurance coverage, claims, prescriptions and referral to and enrollment in this Program for purposes of determining my participation in, and administering, the Program, which may include contacting me as well as my Doctor/Healthcare Provider, office/hospital
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