THE SUPPORT AND RESOURCES TO HELP YOU GET STARTED ON QINLOCK^® (ripretinib)*

By checking the box, and clicking “submit”, I am enrolling in Deciphera AccessPoint for QINLOCK^® (ripretinib) patient support program (the “Program”). I authorize Deciphera Pharmaceuticals and its affiliates, business partners, vendors, and other agents (collectively, “business partners” and together with Deciphera Pharmaceuticals, “Deciphera”) to provide me with services for which I am eligible under the Program, as well as contact me via text and voicemail. Such services may include medication and adherence communications and support, medication dispensing support, insurance coverage and financial assistance support, disease and medication education, and other support services offered now or in the future. As part of the Program offerings, I agree to my enrollment in the copay assistance program if I am eligible. If I am applying for patient assistance (no-cost medication) I authorize the Program to use my personal information to obtain a report on my individual credit history from consumer reporting agencies and use that report and other information collected from public and other sources to verify the information on this form and estimate my income to decide if I am eligible for free medication. Upon request, the Program will provide me the name and address of the consumer reporting agency that provides the consumer report. I understand that free product programs (Rapid Start, Bridge, or Patient Assistance Program) are subject to eligibility criteria and that completing this application does not ensure that I will qualify for these programs. I certify that all the information provided in this application, including household income, is complete and accurate. I understand that program assistance will terminate if the program becomes aware of any fraud. If I receive free product, I will not seek reimbursement for it from any insurer, health plan, or government program. If I receive free product, I will not seek to have this prescription, or any associated cost, counted as part of my out-of-pocket cost for prescription drugs.

AUTHORIZATION TO SHARE HEALTH INFORMATION

By checking this box and clicking "submit", I authorize my health care providers and staff, my pharmacies, and my health insurers to use and to disclose to Deciphera Pharmaceuticals, and its affiliates, business partners, vendors, and other agents (collectively, "Deciphera") health information about me, including information related to my medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for QINLOCK (my "Information") to (1) enroll me in and provide services under the Deciphera AccessPoint for QINLOCK patient support program (the "Program"); (2) obtain information on my insurance coverage; (3) coordinate prescription fulfillment as indicated by my physician; (4) provide me with adherence reminders and support; and (5) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Deciphera support programs or Deciphera products. Once my Information has been disclosed to Deciphera, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand that Deciphera will protect my Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law. I understand and agree that the pharmacy that dispenses my QINLOCK may receive payment from Deciphera in exchange for disclosing my Information to Deciphera and providing Program services. I understand that I do not have to check this box and provide authorization. A decision by me not to check this box and provide Authorization will not affect my ability to obtain medical treatment from my health care providers, my eligibility for health insurance benefits, or my access to Deciphera medications. However, if I do not check this box to provide Authorization, I understand I will not be able to participate in the Program. I understand that this Authorization expires ten years from today's date, or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization at any time by calling 1-833-4DACCES (1-833-432-2237) or by notifying Deciphera in writing at PO Box 5490 Louisville, KY 40255. Cancellation of this Authorization will end further uses and disclosures of my Information and my participation in the Program but will not affect any uses or disclosure of my Information made by my health care providers and staff, my pharmacies, and my health insurers based on this Authorization before receipt of the cancellation. I understand I may request a copy of this Authorization.*