SAMPLE eAUTHORIZATION: CLINICAL SITE INTRODUCTION
By signing this patient authorization (“Authorization”), I authorize Cure Forward for a period of twenty (20) years (unless you are a resident of Minnesota in which case that period will be one (1) year) beginning on the date this Authorization is signed to disclose (i) my genetic test results and other molecular information in its possession, including but not limited to information about my DNA, RNA, chromosomes, proteins, metabolites, and/or other measurable biochemical characteristics (“Genetic Information”) and (ii) other health information about me in its possession, including but not limited to my name, contact information, age, gender, demographic information, health history (e.g., cancer type and stage, medications), and any clinical characteristics that may be relevant to my condition (“Other Health Information”) to Texas Oncology in Arlington, TX (“Site Manager”) for the purpose of allowing Site Manager to collect, use, and retain that information for the following authorized purposes: (i) contacting me regarding research studies, including clinical trials, for which I may be eligible; (ii) assessing whether I am eligible for one or more research studies; and (iii) facilitating my enrollment in one or more research studies for which I am eligible.
By signing this Authorization, I authorize Site Manager for a period of twenty (20) years beginning on the date this Authorization is signed to disclose (i) information about my medical conditions, (ii) information about the nature of Site Manager’s communications with me regarding participation in a research study, and (iii) information about my eligibility for and/or enrollment in a research study to Cure Forward, with address at 263 Summer St., 4th Floor Boston, MA 02210, for the purpose of allowing Cure Forward to provide that information to the clinical trial recruiter responsible for that research study.
I understand that the information I authorize Cure Forward and Site Manager to disclose may not be subject to federal or state health information privacy laws and may be redisclosed in accordance with applicable laws.
I understand that this Authorization is voluntary and that my treatment, payment for treatment, health insurance enrollment, or eligibility for health plan benefits will not be affected if I refuse to sign this Authorization, but if I do not sign this Authorization, I may not be able to use certain of the services Cure Forward makes available to me through www.cureforward.com and other related websites, mobile applications, and other online services operated by Cure Forward and/or I may not be able to participate in the research studies conducted by Site Manager.
I understand that I may revoke this Authorization at any time and for any reason by contacting Cure Forward at [email protected] Cure Forward and/or Site Manager will process any request to revoke this Authorization in accordance with applicable laws.
I understand that Site Manager may retain my Genetic Information [Cure Forward to indicate what the appropriate retention period would be for the Site Manager], unless I earlier request that my Genetic Information be destroyed or I earlier revoke this Authorization. Provided that, in any event, Site Manager may continue to retain my Genetic Information to the extent authorized or required by applicable law.
I understand that I am entitled to receive a copy of this Authorization once it has been signed.
I agree to sign this Authorization electronically. By typing my name and the date where indicated below and clicking the checkbox below I am placing my electronic signature on this Authorization. My electronic signature certifies that I have read and agree to all the provisions of this Authorization and that I am entering into a valid and binding agreement as the patient named below or the authorized personal representative of that patient.
If you are the patient, please provide the requested information and click the checkbox to electronically sign the Authorization:
First Name: _______________ Last Name: ______________________
[ ] By clicking this checkbox I agree to the terms of this Authorization.
If you are the personal representative of the patient, please provide the requested information and click the checkbox to sign the Authorization:
My First Name: _____________ My Last Name: ___________________
Patient’s First Name: __________________ Patient’s Last Name: __________________
My Relationship to the Patient: _______________________________________________
[ ] By clicking this checkbox I certify that I have the legal authority under applicable law to sign this Authorization on behalf of the patient named above and that I agree to the terms of this Authorization on behalf of that patient.