eAuth Diagnostic data request

SAMPLE eAUTHORIZATION: DIAGNOSTIC DATA REQUEST

CURE FORWARD

PATIENT AUTHORIZATION

By signing this patient authorization (“Authorization”), I authorize my health care providers, including my doctors, laboratories, hospitals, and pharmacies (collectively, “My Providers”), for a period of one (1) year beginning on the date this Authorization is signed, to disclose (i) my genetic test results and other molecular information in their 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 their possession, 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”) to Cure Forward, with address at 210 Broadway #201 Cambridge, MA 02139, for the purpose of allowing Cure Forward to collect, use, and retain and, 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 that information 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 Providers, at my request and on my behalf;
  • marketing or advertising products, goods, or services to me or otherwise delivering promotional materials or advertisements that may be of interest to me;
  • 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 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;
  • detecting, preventing, and responding to fraud, intellectual property infringement, violations of Cure Forward’s terms of use, violations of law, or other misuse 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 once my Genetic Information or Other Health Information has been disclosed to Cure Forward, that information 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 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].  Revoking this Authorization will prohibit further disclosure of my Genetic Information and Other Health Information by My Providers, and Cure Forward will process any request to revoke this Authorization in accordance with applicable law.

I understand that Cure Forward may store 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: ______________________

Date: ____________________________

[ ] 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: _______________________________________________

Date: _______________________________

[ ] 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.

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