United Therapeutics

REMODULIN® THERAPY ASSISTANCE PROGRAM
CONSENT FORM

The Remodulin Therapy Assistance Program is a United Therapeutics initiative to provide Remodulin patients with non-medical assistance in support of their Remodulin therapy. This may include providing general information about Remodulin, support group services, insurance assistance, etc.

When you submit this form, a Remodulin Therapy Assistant (RTA) will contact you and introduce herself or himself. You will be asked general questions, such as when you started Remodulin. The RTA will contact you periodically and you are encouraged to contact your RTA as often as you like. While some of the information you provide may be used for quality assurance within United Therapeutics, none of your personal information will be shared outside United Therapeutics. Your personal information will be maintained in a confidential manner, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and United Therapeutics Corporation’s HIPAA Compliance Policy.

By submitting this form, you are creating a no-cost relationship with your dedicated Remodulin Therapy Assistant at United Therapeutics. Your RTA is available to help you!

If you have any questions about the Program that you would like answered before signing this form, please feel free to contact Robert Daye, Manager of the RTA Program (toll free 877.UNITHER or email RTA@unither.com).

YES, I would like to participate in the RTA Program. I understand that an RTA will contact me directly on occasion. I also understand that I may contact the RTA at any time with general questions and concerns. Further, I am free to terminate this relationship at any time.

* Denotes required fields.

*First Name:

*Last Name:

  Home Phone:

  Cell Phone:

*Email Address:

  Address 1:

  Address 2:

  Please have my RTA   contact me at:

  I prefer that my RTA is:

The following links to outside online resources provide information relating to diseases for which United Therapeutics is developing therapies, including clinical trial information, patient associations and disease information. These links are provided for your convenience and are not intended to suggest an affiliation between United Therapeutics and any of the organizations maintaining these sites.

Clinical Trial Information

http://www.clinicaltrials.gov

FREEDOM - M: Oral Treprostinil as Monotherapy for the Treatment of Pulmonary Arterial Hypertension (PAH)

FREEDOM-C: Oral Treprostinil in Combination With an Endothelin Receptor Antagonist (ERA) and/or a Phosphodiesterase-5 (PDE-5) Inhibitor for the Treatment of Pulmonary Arterial Hypertension (PAH)

Pulmonary Hypertension

Priority Healthcare PH Information Site
http://www.phneighborhood.com

Pulmonary Hypertension Association
http://www.phassociation.org/

Peripheral Vascular Disease/
Critical Limb Ischemia

Vascular Web Patient Information
http://www.vascularweb.org/publiceducation/patientinfo.cfm

Peripheral Vascular Surgery Society
http://www.pvss.org/

The Society for Vascular Medicine and Biology
http://www.svmb.org/

Society for Vascular Surgery
http://svs.vascularweb.org/