KaryForward Patient Consent e-Form

*Patient Date of Birth

*Patient's Gender Select Male Female Undisclosed

Patient Consent

I hereby authorize my healthcare professionals, my health insurance company, and my pharmacy to disclose my personally identifiable (“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 (collectively, “KaryForward”) for the purposes described below. I understand that once my PHI has been disclosed to KaryForward, certain federal privacy laws might not protect it and it could be subject to redisclosure, but I also understand that KaryForward intends to share my PHI only as described here or as otherwise permitted by law.

I hereby authorize KaryForward and its agents to use and share my PHI in order to: (1) contact me, or the person legally authorized to sign on my behalf, by phone or mail, (2) contact my insurance company on my behalf to verify my coverage for XPOVIO® (selinexor), (3) 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) determine my eligibility for enrollment in the Dose Exchange Program, (5) provide me with information regarding any independent third-party foundation or other sources of funding that may be available to help cover my out-of-pocket expenses, (6) coordinate my treatment with my healthcare professionals and specialty pharmacy, and (7) send me materials (including promotional materials) regarding products, services, or other information that may be of interest to me.

I understand that signing this authorization is necessary to receive the above-described support from KaryForward, but that if I refuse to sign this authorization, it will not affect my treatment by my healthcare professionals, or my eligibility for or receipt of benefits from my health plan. I also understand that if I sign the authorization, I may withdraw (cancel) it any time by writing to KaryForward at 13410 Eastpoint Centre Dr. Louisville, KY 40223. Withdrawing the authorization may mean I can no longer receive support from KaryForward, but it will not invalidate any uses or disclosures of my PHI made in reliance on the authorization before my notice of withdrawal is received by KaryForward.