eHIPAA

For Questions,
Call Celltrion CONNECT®:
Phone: 1-877-81CONNC (1-877-812-6662)
Fax: 833-912-3707
Website: http://www.CelltrionConnect.com
Hours of Operation:
Monday-Friday, 8:00 AM - 8:00 PM ET
US-ZYM-24-00134 03/24

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About this Site

You have expressed an interest in Celltrion CONNECT® Patient Support Program for ZYMFENTRA™ (infliximab-dyyb).
Your privacy is important to us. In order for us to provide support services, we will need your authorization and consent to use your health information, called Protected Health Information (PHI), and also consent to share your information with your health plan and other companies that support your treatment.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

I am signing as parent or guardian (personal representative) of the patient.

Contact Information

Email Address *

Patient Cell #

555-555-5555

About this Site

Patient Information

Personal Representative Information

Contact Information