By signing this Authorization to Use and Disclose Health Information (the “Authorization”), I hereby authorize My health care providers, including any clinical trial sites I visit as part of considering clinical trial participation, and their vendors (“Providers”) to disclose information to Novartis Pharmaceuticals Corporation, its affiliates, business partners, and agents (“Novartis”) relating to My medical condition, treatment, clinical trial screening, and demographic information (“Health Information”) for the purposes described below:
- Coordinating and evaluating Novartis’ clinical trial recruitment process;
- Collecting and processing information from potential clinical trial participants to screen eligibility for participation in one or more clinical trials;
- Conduct quality assurance, surveys, and other internal business activities;
- Or as otherwise required by law.
I give permission to Novartis to disclose My Health Information to My Providers, insurer(s), caregivers, and other third-party contractors or service providers for the purposes described above. I also give permission to Novartis to combine or aggregate any Health Information collected from me with information Novartis may collect about me from other sources for the purposes described above.
I understand that this Authorization is voluntary. My decision whether to sign this form will not affect My medical care or my eligibility for healthcare benefits.
I understand that I am entitled to receive a copy of this Authorization. I understand that I may revoke (withdraw) this Authorization at any time and for any reason in writing by contacting PatientCentra by emailing firstname.lastname@example.org. Revoking this Authorization will prevent Novartis from further using or disclosing My Health Information for the purposes set forth in this Authorization, but it will not affect uses and disclosures of My Health Information that were already made in reliance on this Authorization, and it will not affect recipients’ ability to use and disclose any of My Health Information that they have already received.
I understand that once My Health Information has been disclosed, My Health Information may be subject to further disclosure by recipients and may no longer be protected by federal health information privacy laws. This Authorization shall remain in effect for one (1) year from the date of my signature, or earlier if required by state law, unless I cancel it sooner.
I understand that the information I provide in this Authorization, [[including my telephone number, address, and email address]] may be used to contact me for all purposes described in this Authorization. I confirm that I am the subscriber for the telephone number provided and the authorized user for the email address provided, and I agree to promptly notify Novartis if my telephone number, address, or email address change in the future. I understand that my wireless service provider’s message and data rates may apply.
If you do not agree to these terms, your eligibility for this specific trial will not continue to be evaluated through this recruitment method. However, you may opt to directly contact the clinical trial site nearest to you. Please click here to see study locations.