Patient Registry Authorization Agreement

Please read the following carefully. The submission of information in the registry will be considered your consent to the following statements.

Authorization Statement for Use and Disclosure of Protected Health Information

The Foundation for Thymic Cancer Research understands that information about your health is personal, and we are committed to protecting the privacy of that information. You are granting your authorization before we use your protected health information (PHI) for the purpose of providing you notification of the availability of clinical studies or trials and updates on the results of clinical studies and trials. This form memorializes your authorization for us to use your PHI for this purpose and helps us make sure that you are properly informed of how this information will be used and/or disclosed.

By agreeing to this document you are permitting the The Foundation for Thymic Cancer Research to use PHI collected about you so that we may contact you with information about availability of clinical studies or trials and provide updates on the results of clinical studies and trials. Please carefully read and understand the information below before clicking “I Agree” below.

1. Who will disclose, receive, and/or use the information?

By clicking “I Agree” you authorize the following person(s), class(es) of persons, and/or organization(s) to be allowed to use and receive the protected health information for the purposes set forth in this form. The PHI will not be disclosed to any parties not named below without your authorization except as permitted by law.

Researchers conducting, or interested in conducting, trials or studies relating to thymoma or thymic cancer ;

In unusual cases, the researchers may be required to release your identifiable medical information from the registry in response to an order from a court of law;

Members of all review boards that oversee this research, including but not limited to the Institutional Review Boards (IRBs);

The entities and persons listed above may employ or pay various consultants and companies to help them understand, analyze and conduct research. You are also authorizing use by and disclosure to such individuals.

2. What information will be used or disclosed?

By clicking “I Agree”, you authorize the use of ALL of your protected health information that you choose to enter in the registry, such as your name, mailing address, birthdate, place of birth, email address, telephone number, facsimile (fax) number, gender, ethnicity, race, name of disease, date of diagnosis of the disease, all of which will be deposited in a secure computerized database. Disclosure of you protected health information will be made to the above named researchers as permitted by law.

3. Expiration date of Authorization:

None

SPECIFIC UNDERSTANDINGS

By clicking “I Agree”, I authorize the list of person(s), class(es) of persons, and/or organization(s) listed above to be allowed to use and receive the information I enter into the registry for the purposes set forth in this form.

I acknowledge that by clicking “I Agree”, the information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by federal privacy regulations or other privacy laws.

I acknowledge that I have a right to refuse to agree to this authorization. I also acknowledge that refusing to click “I Agree” will not affect my health care, the payment for my health care, and my health care benefits, outside of this particular activity. However, I also understand that in order to register myself to participate in the registry, I must agree to the terms of this authorization form and acknowledge my acceptance of this form by clicking “I Agree” once I have read and understood this authorization form.

I acknowledge that if I agree to this authorization, I will have the right to revoke this authorization at any time by clicking Withdraw (located on the “Joining the Registry” webpage) and filling in the required information, except to the extent that the Foundation for Thymic Cancer Research has already taken action in reliance on this authorization.I understand that this revocation will apply only to use of the data in registry after the date of Withdrawal.

I acknowledge that by clicking “I Agree”, this authorization will never expire unless and until I choose to discontinue my enrollment by clicking Withdraw (located on the “Joining the Registry” webpage) and filling in the required information.

Prior to clicking “I Agree”, if I have questions about this authorization form, then I will contact the Foundation for Thymic Cancer Research (at info@thymic.org) and have my questions answered. By clicking “I Agree”, I acknowledge that I have had the opportunity to ask questions about this authorization prior to accepting this authorization.

By clicking “I Agree”, I acknowledge that I have read, understand, and agree to accept this authorization’s terms.

I HEREBY GIVE permission to the Foundation for Thymic Cancer Research to use the information I provide to the patient registry. I understand that if I enter my contact information, I agree to be contacted about future research studies. I understand that if I do provide my name or other contact information, neither will be identified by name or any traceable identification in any report published or distributed without my permission.

By clicking “I Agree” you are agreeing to the terms and conditions of the statements above.

I agree, please take me to the application

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