Stiolto form block

Please make sure your phone is connected to a printer. If not, you can download the Voucher and email it to yourself for printing

You are enrolling your patient into the STIOLTO RESPIMAT Hospital to Home program.

All fields are required unless otherwise noted.

The Hospital to Home Program (the “Program”) includes various offerings, including, patient education, and general adherence support. The Program is funded by Boehringer Ingelheim Pharmaceuticals, Inc. and its affiliates and subsidiaries (collectively, “BIPI”) and is administered in conjunction with certain of its contractors and agents and clinical education contractors (collectively, the “Contractors”).

By checking here, I am authorizing BIPI and its contractors to use the information provided on this form to enroll me in the Hospital to Home program and mail me customized education materials.

By checking here, I am authorizing BIPI to use the information I provided to mail or email me health- and product-related information, including marketing/offers about other BIPI products. If at any time I change my mind regarding participation in the selected program offerings, I understand that I can opt out by contacting Hospital to Home at 844-666-1630 anytime.

Please have the patient read the following HIPAA Authorization.

I understand that the information contained on this form, including my contact information, as well as any other information necessary for my participation in the Program (collectively, “Personal Information”) may contain or otherwise be viewed as a form of “protected health information” as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPAA”).

I understand and agree that:

  • Once my Personal Information has been disclosed to BIPI and the applicable Contractors, federal or state privacy laws may no longer protect the information from further disclosure.
  • I do not have to sign the Authorization. Refusing to sign will not affect the treatment provided by my Health Care Providers in any way. However, I will not be eligible to receive the Selected Program Offerings.
  • This Authorization will remain in effect until I am no longer participating in the Selected Program Offerings, at which time it will expire.
  • I may cancel/revoke this Authorization at any time by contacting the Health Care Providers who assisted with my enrollment in the Program. If I cancel, my Health Care Providers cannot make further disclosures of my Personal Information, but the cancellation is not effective to the extent BIPI and the applicable Contractors, or other parties, have already acted in reliance on this Authorization. If at any time I change my mind regarding participating in the Selected Program Offerings, I understand that I can opt out by contacting Hospital to Home at 844-666-1630.
  • I am entitled to a copy of the Authorization.

PATIENT, by typing your full name in this box and providing either an email address or phone number, this serves as your electronic signature and acceptance of this HIPAA authorization.

Patient Name
Phone Number or Email Address