Forms

To enroll your patient in BioMarin RareConnections™, you must complete the Patient Enrollment Form, which serves as the prescription. Your patient or his/her caregiver must also complete the Patient Authorization Form. Access or download the forms you need to begin enrolling your patient in BioMarin RareConnections.

Patient Enrollment Forms
 (to be completed by the healthcare provider)

BioMarin RareConnections HCP Portal

Download and Print

Use this form to start enrollment in BioMarin RareConnections.

*This form serves as the prescription for your patient's BioMarin treatment.

BRINEURA
(cerliponase alfa)
NAGLAZYME
(galsulfase)
PALYNZIQ*

(pegvaliase‑pqpz)

WARNING: Anaphylaxis has been reported after administration of PALYNZIQ and may occur at any time during treatment with PALYNZIQ. Please see the Important Safety Information, including a Boxed Warning for risk of anaphylaxis, and the full Prescribing Information and Medication Guide.

VIMIZIM

(elosulfase alfa)

WARNING: Life-threatening anaphylactic reactions have occurred in some patients during Vimizim infusions. Please see the Important Safety Information and the full Prescribing Information for additional safety information.

Patient Authorization Form
 (to be completed by your patient)

Online Form

Email

Download PDF

Patients must complete the BioMarin RareConnections Patient Authorization Form (PAF) in order to receive support from BioMarin RareConnections. Through this form, patients grant BioMarin permission to use and disclose their health information in order to help them access BioMarin therapies.

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