SPONSORED XLH GENETIC COUNSELING

WOULD GENETIC COUNSELING BE HELPFUL FOR YOUR PATIENTS WITH XLH?

Genetic counseling is available at no cost

to eligible patients through this Ultragenyx-

sponsored program.

Sponsored by:Counseling by:

QUESTIONS ABOUT SPONSORED GENETIC COUNSELING FOR YOUR PATIENTS WITH XLH?

Contact your UltraCare Liaison to learn more.

For patients with X-linked dominant disorders, such as X-linked hypophosphatemia (XLH), genetic counseling can be an important element in helping them manage their condition, identify family members at risk, and think about family planning.

Ultragenyx has partnered with InformedDNA, a genetic counseling company, to provide sponsored genetic counseling for eligible patients. Program information for patients is available; contact your Ultragenyx representative to request patient brochures.

Who is eligible for sponsored counseling?• Patients or caregivers of patients aged 6 months and older

who have been diagnosed with XLH

For patients meeting the eligibility criteria, this genetic counseling program is provided at no cost.

To refer a patient for sponsored XLH genetic counseling:

You can also complete the form online at: https://informeddna.formstack.com/forms/ultragenyx.

Complete and print the genetic counseling referral form and fax it to InformedDNA at 760-308-6324.

ABOUT THE PROGRAM

Get them started by completing and submitting the genetic counseling referral form.

MRCP-KRN23-00546 02/2020 © 2020 Ultragenyx Pharmaceutical Inc. All rights reserved.

Name:____________________________________________________________________ Date of Birth:__ __ ______

□Phone:____________________ □Phone:___________________ Email:___________________________________

Language Interpreter Needed: □Spanish □Other:________________________________________________

________________________________Medical Center/Practice

________________________________Referring Provider

________________________________NPI

________________________________Practice Contact

________________ _______________ Phone Fax (required)

________________________________E-mail

________________________________Address

_________________ _____ ________ City State Zip

________________________________Referring Provider's Signature

PREFERRED SECONDARY

Bill to Ultragenyx Pharmaceutical, Inc.

This referral form can be used to submit a request for sponsored genetic counseling, a complimentary program brought to you by Ultragenyx Pharmaceutical. Patients must meet the eligibility requirements for the program. To submit orders for genetic counseling outside of this program, please order through InformedDNA's website: www.informeddna.com

Program Eligibility:Patient or caregiver of patient aged 6 months and older diagnosed with X-linked

hypophosphatemia (XLH)

NOTE:AllpatientsprovidedinformationinthisGeneticCounselingReferralformwillremainconfidentialandshall only be used for the purpose of providing referrals related to genetic counseling.

© 2020 Informed Medical Decisions, Inc.

MRCP-KRN23-00525 01/2020

Date ___ ___ ______

Genetic or biochemical test results that support the patient’s XLH diagnosis

* Genetic counseling appointments are sponsored by Ultragenyx Pharmaceutical, Inc. All genetic counseling will be provided by an independent genetic counselor assigned solely by InformedDNA. Ultragenyx does not have any role in the selecting of the genetic counselor.