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; (d) to determine my eligibility for enrollment in the Dose Exchange Program (2) 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; (3) Coordinate my treatment with my healthcare professionals and specialty pharmacy; (4) Send me materials regarding products, services, or other information that may be of interest to me. I understand that once my health information has been disclosed to KaryForward, it could be subject to redisclosure and that federal privacy laws may be no longer protect the information. 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 healthcare 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.
Please see XPOVIO® (selinexor) Full Prescribing Information at XPOVIO.COM.
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