Personal Information for Patient Support
I authorize my healthcare providers (including my doctor(s) and their staff), my pharmacies, my employer and my health insurer(s) to disclose my personal information, which may include any information related to healthcare insurance, benefits, coverage limits, appeals, and health records related to my treatment or other relevant information which CTI BioPharma deems necessary for use in the CTI BioPharma program (“Personal Information”), to CTI BioPharma, its affiliated companies, business partners, and vendors (together “CTI BioPharma”) so that CTI BioPharma can (i) help to verify or coordinate insurance coverage or otherwise obtain payment for the treatment prescribed by my healthcare physician, (ii) coordinate my receipt of product, (iii) provide me with information about product, (iv) contact me throughout therapy to discuss my therapy and provide patient support, (v) conduct market research, surveys, quality assurance, and other internal business activities in connection with the CTI BioPharma program, including but not limited to CTI BioPharma Marketing teams. I understand that my cell phone carrier’s standard rates may apply for calls and texts to my cell phone. I understand and agree that Personal Information transmitted by email and cell phone cannot be secured against unauthorized access. If I qualify for the CTI BioPharma Patient Support Program, I understand that any assistance provided under this program is contingent upon my ability to meet the eligibility criteria for the program as determined by CTI BioPharma.
Use
While CTI BioPharma will only use my Personal Information for the intended purposes described above, I understand that once my Personal Information is disclosed it may be re-disclosed by recipients and will no longer be protected by federal privacy law. I understand my Personal Information may be used by pharmacies to process my prescription. I understand that I may refuse to provide my authorization or in the future opt out of specific components or services of the CTI BioPharma Patient Support Program, and that my refusal will not affect my ability to receive treatment from my healthcare providers. I understand that some pharmacies may receive payment for disclosing my Personal Information in exchange for providing the services associated with the program.
Medicare Beneficiaries
I also understand that any medicines I may receive from this program are only for me and I agree that I will not give them to anyone else and if I am a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug Plan beneficiary, that I may not submit a claim for payment to Medicare or any third-party payer, and no part of the payment for the product provided hereunder will be claimed as part of my true out-of-pocket expense (TrOOP).
Text and Email
I authorize my text and email information for use in contacting me as a means of additional support as I begin taking CTI BioPharma's products. I understand I will have the specific option of opting out of a text or email engagement and opting out will not revoke the above consent for personal information for patient support and use. To revoke a consent entirely, please follow the revocation instructions.
Timeframe, Copy, and Revocation
I understand that this Authorization will remain valid for five (5) years from this date unless I revoke it earlier. I also understand that CTI BioPharma's programs may change or end at any time without prior notification. I also understand that I can obtain a copy of my signed Authorization upon request and that I can revoke this Authorization at any time by calling CTI Access® at 888-CTI-FORU (888-284-3678) or by writing to the CTI Access® program located at 50 Bearfoot Road, Northborough, MA 01532.
