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 age, my health history (e.g., cancer type and stage, medications), information regarding the locations where I would be willing to receive care, and any clinical characteristics that may be relevant to my condition (“Other Health Information”) to clinical trial recruiters with which Cure Forward has partnered (“Clinical Trial Recruiters”) for the purpose of allowing the Clinical Trial Recruiters to collect, use, and retain that information for the following authorized purposes: (i) assessing whether I may be eligible to participate in one or more research studies, including clinical trials, and (ii) contacting me about those research studies. The names and addresses of the Clinical Trial Recruiters to which Cure Forward may disclose my Genetic Information and Other Health Information are available at: www.cureforward.com.
I understand that the Genetic Information and Other Health Information I authorize Cure Forward to disclose may not be subject to federal and 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.
I understand that I may revoke this Authorization at any time and for any reason by contacting Cure Forward at [email protected]. Cure Forward will process any request to revoke this Authorization in accordance with applicable law.
I understand that my Genetic Information may be stored 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.