By signing this patient authorization (“Authorization”), I authorize Cure Forward, 263 Summer St., 4th Floor Boston, MA 02210, to collect, receive, analyze, use, retain and disclose:
The following information:
- My genetic test results and other molecular information, including but not limited to information about my DNA, RNA, chromosomes, proteins, metabolites, and/or other measurable biochemical characteristics (“Genetic Information”) and
- Other health information about me, including but not limited to my health history (e.g., cancer type and stage, medications) and any clinical characteristics that may be relevant to my condition (“Other Health Information”)
From the following sources:
- Information that I provide directly to Cure Forward;
- Information that Cure Forward receives from my health care providers, including my doctors, laboratories, hospitals and pharmacies (collectively “My Providers”) pursuant to my authorization
- Information that Cure Forward receives when I have requested access to my health information from My Providers and have designated Cure Forward as the third party to receive the requested information on my behalf
For the following period of time:
- Twenty years from the date this Authorization is signed, except with respect to residents of Minnesota;
- Residents of Minnesota:
- Twenty years from the date this Authorization is signed to collect, receive, analyze and retain my information.
- One year from the date this Authorization is signed to disclose my information to others.
For the following authorized purposes:
- facilitating the provision of my Genetic Information and/or Other Health Information to and the receipt of my Genetic Information and/or Other Health Information from my healthcare providers, at my request and on my behalf;
- contacting My Providers in the event they may have information that is helpful to another healthcare provider;
- providing me with the services or information I request;
- identifying genetic test result similarities between me and other users of www.cureforward.com and all related websites, mobile applications, and other online services operated by Cure Forward (collectively, the “Online Services”);
- connecting me with other users of the Online Services or my healthcare providers, at my request;
- reviewing my Genetic Information and/or Other Health Information alone, or in combination with the information of other users of the Online Services, to identify users of the Online Services who fit health or genetic-related criteria specified by Cure Forward;
- identifying clinical trial opportunities for which I may be eligible or that may be of interest to me and contacting me about those opportunities;
- providing personalized educational resources to me;
- operating the Online Services, including improving the Online Services, providing me with information about the Online Services, and generating and analyzing statistics about use of the Online Services;
- de-identifying my Genetic Information and/or Other Health Information by removing information typically used to identify individuals, including name, address, phone number, and email address (the resulting information is referred to in this Authorization as “De-identified Information”);
- using and disclosing my Genetic Information and/or Other Health Information as otherwise required by law;
- providing the features of the Online Services, including the social networking features of the Online Services, that I elect to use (e.g., facilitating my election to share my Genetic Information and/or Other Health Information with other users of the Online Services), or any other services that I request when using the Online Services; or
- for purposes otherwise authorized by me.
After Genetic Information or Other Health Information is used to create De-identified Information, Cure Forward may use, disclose, and retain indefinitely that De-identified Information for research purposes.
I understand that the Genetic Information and Other Health Information disclosed to Cure Forward 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 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 the Online Services.
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 laws.
I understand that Cure Forward may store my Genetic Information for up to twenty years unless I request that Cure Forward destroy my Genetic Information or I revoke this Authorization.
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.