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Enroll in Kyowa Kirin Cares

Enroll in Kyowa Kirin Cares

Kyowa Kirin Cares is a program that offers support for patients who have been prescribed CRYSVITA® (burosumab-twza). Dedicated team members from Kyowa Kirin Cares can connect you to resources and tools based on the support you need. As always, your doctor will continue to provide medical advice and act as your primary point-of-care.

Are you a Patient or a Patient Authorized Representative? * Mandatory fields.

Patient Authorization

Patient Authorized Representative

By selecting “Yes,” I confirm this is my phone number and agree to subscribe to the Kyowa Kirin Cares Text Message program. I understand the amount of texts I received may vary based on the progress of my enrollment. Full Text Message program terms and conditions.

Patient Authorization for Health Information use and Disclosure

Patient Authorization for Health Information use and Disclosure

By clicking submit, I authorize each of my prescribers, pharmacists, including any specialty pharmacy that receives my prescription for CRYSVITA® (burosumab-twza) and other healthcare providers (together “Healthcare Providers”) and each of my health insurers (together, “Insurers”) to disclose my Protected Health Information, including but not limited to medical records, information related to my medical condition and treatment, my health insurance coverage, my name, address, telephone number, Social Security number, insurance plan and or group numbers (together, “Protected Health Information”) to Kyowa Kirin, its affiliated companies, vendors, agents, collaboration partners, and representatives (together, “Kyowa Kirin”) including providers of alternate sources of funding for prescription drug costs, and other service providers supporting Kyowa Kirin Cares Support Services (the “Program”) for Healthcare Providers and patients for the purposes described below.

Specifically, I authorize disclosure of my Protected Health Information in order to:

  • I.Enroll me in, and contact me about the Program, including online support, financial assistance services, co-pay assistance, specialist services, and compliance and persistency services
  • II.Communicate with my Healthcare Providers and Insurers about benefits, coverage and medical care, including compliance with Product treatments
  • III.Locate a specialty pharmacy that can fill my prescription and facilitate dispensing of my prescription by such pharmacy
  • IV.Provide me with educational materials, information and services related to my treatment experience with CRYSVITA and my condition
  • V.Contact me and leave messages about my use of CRYSVITA and my medical care
  • VI.Verify, investigate, assist with, and coordinate my coverage for CRYSVITA with my Insurers
  • VII.Coordinate prescription fulfillment
  • VIII.Conduct surveys, data analytics, market research and other internal business activities related to the Program, CRYSVITA, and other Kyowa Kirin products and programs
  • IX.Contact me as otherwise required or permitted by law
  • I understand that pharmacies that ship my medication may be paid to share this information with the Program to help provide the offerings requested for me. Once my Protected Health Information has been disclosed to Kyowa Kirin, I understand that federal privacy laws no longer protect the information. However, Kyowa Kirin agrees to protect my Protected Health Information by using and disclosing it only for the purposes described in this Authorization or as permitted by law.

    I understand that I may refuse to sign this Authorization. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me, but I will not have access to the Program and the services provided by Kyowa Kirin under the Program. If I refuse to sign the Authorization, or revoke my authorization later, I understand that this means I will not be able to participate or receive assistance from the Program.

    This Authorization will last for a period of five (5) years (unless earlier termination is required by applicable state law). I understand that I may cancel this Authorization at any time in the future, except to the extent that actions have been taken in reliance on the Authorization, by mailing a request to 212 Carnegie Center Dr, Suite 400, Princeton, NJ 08540, via fax at 833-552-3299, or by calling 833-552-2737. I understand that revoking this Authorization will end further uses and disclosure of my Protected Health Information by the parties identified above except to the extent those uses and disclosures have been made in reliance upon this Authorization as permitted by applicable law. I am entitled to receive a copy of this Authorization.

    The personal information and health insurance I have provided on this form is complete and accurate to the best of my knowledge. I will update my information promptly if any of the information reflected on this form changes by contacting the Program at 833-552-2737.

    Please provide a signature to acknowledge this form.

Kyowa Kirin Cares is a program that offers support to patients who have been prescribed CRYSVITA® (burosumab-twza). If you are interested in receiving information about CRYSVITA via email, please read below and then click SUBMIT.

In addition, please feel free to make use of the resources available at

If you are prescribed CRYSVITA at a later time, please contact us again if you are interested in participating in the Program.

By clicking SUBMIT and providing your name, email address, or other personal information, you agree that Kyowa Kirin and others working on behalf of Kyowa Kirin may send you content updates and educational materials about XLH/TIO and CRYSVITA, use the information that you have submitted to develop or improve products and services, and contact you in the future about educational programs, health-related topics, and advancements in the treatment of XLH/TIO. Kyowa Kirin respects the privacy of visitors to its websites, and we recognize your need for protection and management of personally identifiable information you share with us (any information by which you can be identified, including, but not limited to, name, address, email address, and telephone number). Click here to read the Kyowa Kirin Privacy Policy.