KaryForward Patient Consent e-Form

Patient Consent

I hereby authorize my healthcare professionals, my health insurance company, and my pharmacy to: (1) 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; (a) To contact me, or the person legally authorized to sign on my behalf, by phone or mail, (b) to contact my insurance company on my behalf to verify my coverage for XPOVIO® (selinexor), (c) to determine my eligibility for enrollment in the XPOVIO® Copay Program and for enrollment into the Patient Assistance Program (PAP), including verification of my financial information; (2) Recommend an independent third-party foundation for assistance or alternate sources of funding or coverage that may be available to provide assistance with out-of-pocket expenses; (3) Coordinate my treatment with my healthcare professionals and specialty pharmacy, and send me educational materials or other program information that may be of interest to me. (4) Once my health information has been disclosed to KaryForward, I understand that federal privacy laws may no longer protect the information. (5) However, I understand that Karyopharm Therapeutics and other companies authorized to receive my health information pursuant to this Authorization agree to protect my health information by using and disclosing it only for purposes authorized in this Authorization or as required by law or regulations. (6) I understand this authorization does not affect treatment from my healthcare professional or coverage for XPOVIO® (selinexor) through my insurance. (7) I understand this authorization is voluntary. (8) However, if I refuse to sign, or cancel my authorization, KaryForward may not be able to determine my eligibility for the XPOVIO® Copay Program and the Patient Assistance Program (PAP). (9) If I do not withdraw the 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