Alnylam Assist®
Online Start Form

Help your patients get started on AMVUTTRA® (vutrisiran) by filling out the online Start Form together.

The purpose of this form is to permit Alnylam Assist® participants to receive additional information and support (“Patient Support”) from Alnylam Pharmaceuticals, Inc., its affiliates, representatives, agents, and contractors (“Alnylam”). Alnylam Assist® provides Patient Support to eligible patients who have been prescribed an Alnylam medicine. This includes: (1) providing reimbursement and financial support to eligible patients (such as investigating your patient's insurance coverage, confirming out-of-pocket costs, and reviewing eligibility for financial assistance); (2) working with you and your provider to fill your prescription; (3) providing you with disease and medication-related educational resources and communications; and (4) contacting you to participate in disease and medication-related market research panels or surveys. Your authorization in this form will relate to information and support with respect to any Alnylam medicine you have been prescribed or may be prescribed in the future.

PLEASE NOTE: Consent via electronic signature is mandatory for submission of the form. Forms must be submitted once started, as progress will not be saved. The online Start Form below should only be used if you and the patient are filling it out together currently. If patient is not present, complete a hard copy of the Start Form and fax to 1-833-256-2747 and an Alnylam Case Manager will follow up to obtain patient consent.

  • Patient Information
  • Insurance Information
  • Prescriber Information
  • AMVUTTRA® (vutrisiran) Prescription

Patient Information

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I have read and agree to the Patient Authorization and Support Program Authorization below

Authorization to Share Protected Health Information

I authorize my healthcare providers, including my physicians and pharmacies (“My Providers”) and my health insurance plan (“My Plan”) to share my medical information (such as information about my diagnosis, prescriptions, and treatment) and my insurance information (“My Information”) with Alnylam so that Alnylam can provide Patient Support. I authorize My Providers to use My Information to provide me with certain offerings related to my treatment and any Alnylam medicine My Providers may prescribe for me at any time. I understand that my pharmacy will receive payment from Alnylam for disclosing My Information to Alnylam. I understand that once My Information has been disclosed, federal privacy laws may no longer protect the information. However, I understand that Alnylam agrees to protect My Information by using and disclosing it only for purposes described in this Authorization or as required by law. I understand that I may refuse to sign this Authorization, and that my treatment, insurance enrollment, and eligibility for insurance benefits are not conditioned upon signing this Authorization.

I also understand, however, that refusing to sign this Authorization means that I may not participate in Alnylam Assist® and may not be able to take advantage of other offerings by Alnylam. I may cancel or revoke this Authorization at any time by mailing a letter to Privacy Officer at Alnylam, Attn: Legal Department, 675 West Kendall Street, Cambridge, MA 02142 or by sending an email to privacy@alnylam.com. I understand that if I revoke this Authorization, My Providers and Alnylam will stop using and sharing My Information under this Authorization, but my revocation will not affect uses and disclosures of My Information prior to my revocation in reliance upon this Authorization. This Authorization expires ten (10) years from the date signed on page 1, or earlier if required by state or local law, unless I revoke it before then. I understand that I may receive a copy of this Authorization. For information about how your personal data are processed as a part of our program, please visit www.alnylampolicies.com/privacy.

Authorization for Alnylam Assist® and Communications

I confirm I would like to enroll in the Alnylam Assist® program and authorize Alnylam to provide me with Patient Support. I understand that Alnylam Assist® is an optional program. I agree that Alnylam may use My Information and share it with My Providers or My Plan in connection with providing the Patient Support, administering the Alnylam Assist® program, or as otherwise required by Alnylam to meet its legal obligations. For example, Alnylam may communicate with me (such as by mail, phone, email, and/or text message) or my caregiver, use My Information to tailor the Alnylam Assist®–related communications to my needs, and share information with My Providers about dispensing Alnylam medicine to me. I understand that Alnylam may de-identify My Information, combine it with information about other patients, and use the resulting information for Alnylam’s business purposes. I understand that the administration of the program might involve the use of artificial intelligence technologies to process My Information and that Alnylam and their third-party vendors might de-identify My Information for machine learning purposes.