KaryForward Patient Consent e-Form

Patient Consent

I hereby authorize my healthcare professionals, my health insurance company, and my pharmacy to disclose my protected health information (PHI) including, but not limited to, my name, address, telephone number, medical records, health insurance coverage, and financial information to KaryForward and its agents. I understand that once my health information has been disclosed to KaryForward, it could be subject to redisclosure and that federal privacy laws may no longer protect the information. I hereby authorize KaryForward and its agents (1) To contact me, or the person legally authorized to sign on my behalf, by phone or mail, (2) to contact my insurance company on my behalf to verify my coverage for XPOVIO® (selinexor), (3) to determine my eligibility for enrollment in the XPOVIO® Copay Program and for enrollment in the Patient Assistance Program (PAP), including verification of my financial information, (4) to determine my eligibility for enrollment in the Dose Exchange Program, (5) Provide me with information regarding any independent third-party foundation or alternate sources of funding or coverage that may be available to provide assistance with out-of-pocket expenses, (6) Coordinate my treatment with my healthcare professionals and specialty pharmacy, and (7) Send me materials regarding products, services, or other information that may be of interest to me. I understand that Patients with insurance plans or employers participating in an alternate funding program (also sometimes referred to as patient advocacy programs, among other names) requiring them to apply to a manufacturer’s patient assistance program or otherwise pursue specialty drug prescription coverage through an alternate funding vendor as a condition of, requirement for, or prerequisite to coverage of relevant Karyopharm products, or that otherwise denies, restricts, eliminates, delays, alters, or withholds any insurance benefits or coverage contingent upon application to, or denial of eligibility for, specialty drug prescription coverage through the alternate funding program are not eligible for the KaryForward PAP program. I understand that if I refuse to sign this authorization, it will not affect my treatment by my healthcare professionals, or my payment, enrollment, or eligibility for benefits from my health plan. However, if I refuse to sign this authorization, or sign and then withdraw my authorization at a later date, it may affect my ability to participate in KaryForward. If I do not withdraw authorization, it will remain valid for 3 years (or at such lesser time as state law may require). I understand I am entitled to receive a copy of this authorization.