Personal Information for Patient Support
I authorize my doctor(s), healthcare providers, health plan or payer, and my pharmacy to disclose to Sobi Inc. (“Company”) and its third party suppliers, vendors, and other service providers supporting VONJO Connect (collectively, the “Service Providers”) information about me (for example, my name, address, insurance policy number, and income) and my medical condition (for example, my diagnosis or medications) (together, “Protected Health Information and/or Personally Identifiable Information”). This Personally Identifiable Information can include spoken or written facts about my health and insurance benefits. It can include copies of records from my healthcare providers or health plans about my health or healthcare. I understand that my healthcare providers and my pharmacy may receive remuneration, or payment, for disclosing my information pursuant to this Authorization. I understand that Service Providers may be compensated by Sobi. The Service Providers will use and give out my information to (i) assist in my enrollment in VONJO Connect and to contact me and/or the person legally authorized to sign on my behalf; (ii) provide me and/or the person legally authorized to sign on my behalf with educational material and other information materials related to the VONJO Connect offerings; (iii) verify, investigate, assist with, and coordinate my coverage for VONJO® (pacritinib) with my payer; (iv) coordinate prescription fulfillment; (v) assess my eligibility for patient assistance and/or benefits, if necessary and applicable; and (vi) assist with analyses of the efficiencies and performance of services provided by Service Providers.
If I am found eligible, I agree to enrollment in the VONJO Copay Assistance Program. In some instances, the Service Providers may de-identify my information and use or disclose the de-identified information (in individual or aggregated form) for any legitimate business purposes. I understand that the Service Providers will make reasonable efforts to keep my information private; however, I understand that once my information has been disclosed to the Service Providers, how the Service Providers further disclose my information may no longer be protected under federal and state privacy laws. This Authorization will last for three (3) years from the date of my signature or until I am no longer receiving VONJO® (pacritinib) or enrolled in VONJO Connect, whichever is later, unless a shorter period is mandated by state law. I understand that I do not have to sign this Authorization, but if I do not, I may not be able to have my insurance coverage verified, have alternate sources of assistance researched, or access other support provided by or on behalf of VONJO Connect. My choice as to whether to sign this form will not change the way my doctors, healthcare providers, or payers treat me. If I no longer wish to participate in VONJO Connect, I shall inform my healthcare providers and/or the administrators of VONJO Connect in writing that I do not want them to share any more information with the Service Providers, but it will not change any actions that took place before I told them. I have the right to revoke or cancel this Authorization, in writing, at any time by providing written notice to my healthcare providers and/or the administrators of VONJO Connect at 50 Bearfoot Road, Northborough, MA 01532. Cancellation of this Authorization will be valid when received by the administrators of VONJO Connect. I understand that a cancellation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I know I have a right to see or request a copy of the information my healthcare providers or payers have given to the Service Providers.
I agree to allow Service Providers to contact me via email or cell phone using the contact information provided in this form, unless I otherwise inform VONJO Connect that I do not wish to receive text messages. I understand that receiving text messages is optional and I can participate in VONJO Connect without agreeing to receive text messages. I understand that by providing my cell phone number on this form I agree to receive text messages with the following conditions: •Service Providers may send an autodialed pre-recorded text message (standard text message and data rates apply). •I can opt out at any time by calling 1-888-284-3678 or replying “STOP” to the text messages. •Service Providers are not responsible if a communication is not delivered due to technical difficulties like server issues, phone carrier outages, or discontinued service. •I am aware that anyone who can open or have access to my phone might see the text messages. •If my mobile operator is not participating in text messaging services, I will not receive text messages. •I CANNOT report product complaints or adverse events (like side effects) by text message. To report these, please call VONJO Connect that I do not wish to receive text messages. I understand that receiving text messages is optional and I can participate in VONJO Connect without agreeing to receive text messages. I understand that by providing my cell phone number on this form I agree to receive text messages with the following conditions: •Service Providers may send an autodialed pre-recorded text message (standard text message and data rates apply). •I can opt out at any time by calling 1-888-284-3678 or replying “STOP” to the text messages. •Service Providers are not responsible if a communication is not delivered due to technical difficulties like server issues, phone carrier outages, or discontinued service. •I am aware that anyone who can open or have access to my phone might see the text messages. •If my mobile operator is not participating in text messaging services, I will not receive text messages. •I CANNOT report product complaints or adverse events (like side effects) by text message. To report these, please call VONJO Connect at 1-888-284-3678. This Authorization Statement is governed by and interpreted in accordance with the laws of the state of Massachusetts, excluding Massachusetts conflict of law rules, and applicable federal law.
