Patient Signature. Date: Signature: Print Name: If not the patient, indicate relationship to patient: ABBVIE’S ADDRESS Attention: Privacy Officer AbbVie, Inc. 0 Xxxxx Xxxxxxxx Xxxx Xxxxx Xxxxxxx, Xxxxxxxx 00000 ORASURE’S ADDRESS Attention: General Counsel OraSure Technologies, Inc. 000 Xxxx Xxxxx Xxxxxx Xxxxxxxxx, Xxxxxxxxxxxx 00000 2 To be determined in accordance with applicable state law prior to use. EXHIBIT E MARKETING CONSENT FORM See attached DRAFT – Subject to Revision as Required by State Law Authorization to Enroll in the AbbVie Care Program and Patient Care Database AbbVie and OraSure would like to make you aware of a patient support program provided by AbbVie to help newly diagnosed Hepatitis C patients understand and better manage their disease (the “Care Program”). The Care Program includes support services at no additional charge, such as access to HCV education and live support from AbbVie’s HCV patient educators. Please carefully read all of the information below. If, after reading this information, you would like to enroll in the Care Program and the Patient Care Database, please sign the authorization. Patient Authorization I authorize OraSure and AbbVie to use certain information about me: my date of birth, gender, ethnicity and contact information, my OraQuick HCV Rapid Antibody Test results and my insurance information (collectively “Private Information”). My Private Information may be provided directly by me or through my health care providers. My Private Information will be used only in connection with the Care Program, including AbbVie’s Patient Care Database and will only be used to: • Allow AbbVie’s Patient Educators to contact me about issues related to Hepatitis C; • Administer the Care Program, which may require AbbVie or OraSure to disclose my Private Information to third parties that AbbVie or OraSure hire to help administer the Care Program and the Patient Care Database; • Contact me by mail, email, or phone with marketing information about AbbVie products or services that relate to Hepatitis C; or • Contact me by mail, email, or phone about my participation in the Care Program. OraSure and AbbVie will use appropriate safeguards to protect my Private Information and will not use or disclose my Private Information other than as described in this authorization without my permission. OraSure and AbbVie will not sell or transfer my Private Information to any third party for such third party’s use of any kind that does not relate to the Care Progr...
Patient Signature. Name (PRINT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I understand that I may receive sedative medication (or, in some cases, a general anaesthetic) during my procedure. The side-effects and risks associated with receiving sedation have been fully explained to me. If I am to receive a general anaesthetic, I will have the opportunity to discuss the details and risk of anaesthesia with an anaesthetist before the procedure. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. to the procedure or course of treatment described on this form. I agree Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of this form which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form. Statement of patient Date . . . . . . . . . . . . . . . . . . . . . . . .
Patient Signature. Name (PRINT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . any sample of my blood for the purpose of cross matching in any circumstances or for any reason whatsoever. the administration of non blood volume expanders such as Saline, Dextran, Haemacel, Hetastarch and Ringers solution. ALL the clinical staff and hospital from all responsibility, and from any liability to me, or to my estate, or to my dependants, for any damage or injury which may be caused to me, arising out of or in connection with my refusal to consent to receive a blood transfusion and / or blood products. will allow: Accordingly I absolve: to me of blood products to me of a blood transfusion The administration: The use of: I HEREBY EXPRESSLY WITHHOLD MY CONSENT TO AND FORBID: (Please tick as appropriate) Refusal for blood transfusion (To be completed by the patient where appropriate) Date . . . . . . . . . . . . . . . . . . . . . . . .
Patient Signature. Date: You can withdraw consent to electronic communications at any time by contacting our office or calling:
Patient Signature. If Patient is a minor, then name and signature of patient’s parent or legal guardian Name of Patient’s Parent or Legal Guardian Signature Date Appendix A MONTHLY MEMBERSHIP PROGRAM SERVICES Appointments. All appointments will be at the discretion and scheduling of Practice. Practice does not provide walk-in urgent care services. Practice strives to see Patients in a timely manner during normal business hours, which are: . Same-day appointments must be scheduled no later than The last appointment of the day is Xx. New Patients and Wellness visits will not be scheduled for same day appointments and must be scheduled at least one week in advance. For Patients with acute issues, Practice will attempt to see Patients within 24-48 hours if medically necessary during regular office hours. After-hour Communications. After-hour Communications. Outside of normal business hours, Patients may call or message Practice’s provider every day including holidays and weekends. Practice’s provider will make every effort to address Patient’s medical needs in a timely manner, but Practice cannot guarantee provider’s availability, and cannot guarantee that Patient will not need to seek treatment in an urgent care or emergency department setting. Calls or messages outside of normal hours are reserved for urgent/acute clinical concerns only. Appointment requests, prescription refills, Program questions and routine health care concerns or questions will not be addressed outside of normal business hours. Routine or continued disregard of this requirement may result in termination of Patient’s membership in the Program.
Patient Signature. I understand that to receive long-term opioids I must agree to my opioid treatment plan by signing this consent form. • Someone has explained the treatment, what it is for, and how it could help me. • Someone has explained things that could go wrong, including serious side effects and death, particularly if I do not take my medicine as prescribed. • Someone has told me about other treatments that might be done instead, and what would happen if I have no treatment. • I understand the importance of: o Telling my provider about side effects. o Telling my provider about changes in my pain and daily function. o Getting my opioid prescription from only my primary pain management provider and no one else. o Not giving away (or selling) my opioids to other people.
Patient Signature. Date: / / If signed by someone other than patient, indicate legal relationship to patient: Witness Signature: _ Date: / / _ APPOINTMENT AGREEMENT _ _ _ / / _ First Name Last Name Date of Birth Appointment Cancellation Policy To our valued patients: We do our best to schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. That’s why it is very important that you keep your scheduled appointment with us and arrive on time. As a courtesy and according to your selected preferences on your HIPAA form, Enliven Medical Clinic sends email, text and phone reminders 4 days, 3 days, and 2 days, respectively, in advance of the appointment time. In addition, if text notifications are selected by the patient there is a “last-minute” reminder message that goes out. Although these reminders can be helpful, please do not rely on them as the sole method to keep track of your upcoming appointments. Instead, please record your appointment on your calendar. If your schedule changes and you cannot keep your appointment, please contact us so we may reschedule you. As a courtesy to our office as well as to those patients who are on our WAIT LIST to schedule with the physician, please give us at least 24 hours’ notice. If you do not cancel or reschedule your appointment with at least 24 hours’ notice, after repeated occurrences we may decide to assess a $25 “no-show” service charge to your account and $35 for any additional “no-shows”. This “no-show” charge is not reimbursable by your insurance company. You will be billed directly for it. After three no- shows in a 12-month period, our practice may decide to terminate its relationship with you. I understand the “no-show” policy of Enliven Medical Clinic. Patient Signature: Date: / _/_ Please Complete: MC/VISA/AMEX / DISC Credit Card # _ Expiration Date: / / CARDHOLDER
