VEPPANU Patient Enrollment

Enroll now with RIGEL ONECARE for reimbursement support, financial assistance, and temporary supply. Fields marked * are required.

Patient Information

Tell us about yourself so we can set up your support.

First Name*

Middle Initial

Last Name*

Date of Birth*

Gender*

Male Female Other

Address

Street Address*

City*

State*

Zip Code*

Contact

Primary Phone*

Home Mobile Work

Secondary Phone

Home Mobile Work

Alternate Contact / Caregiver (optional)

Name

Primary Phone

Step 1 of 5

Patient Insurance

Providing insurance coverage details and copies of insurance card(s) is optional but may help speed up the benefit investigation process.

Patient is uninsured

Primary Health Insurance

Name

Phone #

Policy ID #

Group #

Policy Holder Name

Holder DOB

Primary Prescription Insurance

Name

Phone #

Policy ID #

Rx Group #

Rx BIN

Rx PCN

Secondary Health Insurance (if applicable)

Name

Phone #

Policy ID #

Group #

Policy Holder Name

Holder DOB

Insurance Documents (optional — attach one or more; PNG / JPG / PDF)

Prescription Insurance

Drop files hereor click to browse · multiple allowed

Medical Insurance (primary, secondary, tertiary)

Drop files hereor click to browse · multiple allowed

Step 2 of 5

Prescriber

Your prescribing healthcare provider, so we can coordinate with their office.

Prescriber First Name*

Prescriber Last Name*

Office Phone #*

Practice / Institution Name

Step 3 of 5

Patient Authorization & Consent

Rigel's privacy notice, patient authorization, and release. Please read in full, then sign.

Authorization Regarding Personal Information for Patient Support

Rigel has programs available to support patients and we will use the information provided to see which program, based on its criteria, you may qualify for. Please read the following carefully, then sign and date.

By signing below, I authorize my healthcare providers (including my doctor(s) and their staff), my pharmacies, and my health insurer(s) (my “Health Team”) to disclose to Rigel Pharmaceuticals, Inc., its affiliated companies, business partners, contractors, and vendors (together “Rigel”) my personal information as needed for my participation in the RIGEL ONECARE program (the “Program”), including my contact information, information related to my healthcare insurance, health records related to the medicine indicated at the top of this form (the “Product”), and my treatment for related conditions (collectively, my “Personal Information”). I authorize Rigel to use my Personal Information to:

(i) help to verify or coordinate insurance coverage or otherwise obtain payment for my treatment with the Product, (ii) coordinate my receipt of the Product, (iii) provide me with information about the Product, (iv) contact me throughout my treatment with the Product to discuss my treatment and provide related support, and (v) conduct program improvement and other internal business activities in connection with the Program (including market research, surveys, quality assurance), and I authorize Rigel to share my Personal Information with my Health Team for the same purposes. I understand and agree that Personal Information transmitted by email and cell phone cannot be secured against unauthorized access. I understand that:

• While Rigel intends to use my Personal Information only as described above, once my Personal Information is disclosed pursuant to this authorization, it may no longer be protected by certain federal privacy regulations and might be disclosed to others.

• Rigel (i) will not use my Personal Information for promotional marketing purposes unrelated to the Program, (ii) uses reasonable administrative, technical, and physical safeguards to protect Personal Information, and (iii) has an applicable Privacy Policy at https://www.rigel.com/privacy-policy.

• I may refuse to sign this authorization or, in the future, withdraw it by writing to Rigel at RIGEL ONECARE, 11800 Weston Pkwy, Cary, NC 27513, and that providing the authorization is not a condition for me to receive treatment (including with the Product) or health insurance coverage, but that I may not participate in the Program unless I provide this authorization.

• If I do withdraw the authorization, that will not invalidate any uses or disclosures made in reliance on the authorization before my written notice of withdrawal is received by Rigel.

• My pharmacy may receive payment from Rigel for disclosing and using my Personal Information in exchange for providing program-related administrative or patient support services, including education related to my therapy.

• This authorization will expire 5 years after I sign it below, unless I withdraw it earlier or state law requires an earlier expiration date.

• I am entitled to receive a copy of this authorization after I have signed it below.

ⓘPlease scroll to the end of the authorization above to enable the acknowledgement and signature.

Additional Communication Release (optional)

Patient / Representative SignatureOptional

ⓘ Signing here is optional. Check the box below to sign electronically — you'll be taken to DocuSign to complete your signature after you submit. Leave it unchecked and we'll send your completed form to RIGEL ONECARE unsigned — the team will contact you to obtain your signature.

I authorize this enrollment and agree to sign it electronically via DocuSign. I am signing as the patient's authorized representative.

Step 4 of 5

Review & Submit

Confirm the information below before submitting.

Patient

Name

Date of Birth

Gender

Primary Phone

Address

Insurance & Documents

Uninsured

Primary Health Plan

Primary Rx Plan

Secondary Health Plan

Documents Attached

Prescriber

Name

Office Phone

Authorization & Signature

Personal Information Authorization

Communication Release

Authorization to Sign

Step 5 of 5

© 2026 Rigel Pharmaceuticals, Inc. All rights reserved. RIGL_FRN-26045 0726
VEPPANU is a trademark of Rigel Pharmaceuticals, Inc. RIGEL ONECARE is a registered trademarks of Rigel Pharmaceuticals, Inc.
RIGEL ONECARE is a patient support center sponsored by Rigel Pharmaceuticals, Inc.

VEPPANU Patient Enrollment

Patient Information

Patient Insurance

Prescriber

Patient Authorization & Consent

Review & Submit

Enrollment Submitted