Your privacy is important to us. By clicking Submit, you confirm that you have reviewed our privacy policy and agree to our terms of use and that your information may be shared with RCA and affiliated companies, who may contact you to keep you updated with important health-related information.

By entering your mobile number and clicking Submit, you also consent that RCA and affiliated companies may send you SMS messages using autodialing technology from our primary messaging code 1-484-209-3355 for health-related information and as described in our terms of use in our privacy policy. Std. msg & data rates apply. Reply HELP or help, STOP to cancel. Msg freq may vary.Your consent is not required as a condition of purchasing any product, good, or service.

Informed Consent to Participate in Medical Record Registry

GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record registry to help Us predict, prevent, and treat disease (the “Registry”). The Registry matches patients’ laboratory test information with medical history information obtained from health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will use data analytics, artificial intelligence and other automated tools to analyze the data in the Registry for various purposes including improving Our patient care and outcomes, lowering costs, recommending products and services to support your health and wellbeing, or sharing data with other healthcare providers, medical researchers, drug developers, and clinical trial teams to advance medical science.

SUMMARY OF INFORMATION

• This Informed Consent and Authorization asks for your permission to participate in the Registry by allowing Us to obtain, store, use and share your information.
• Participation is voluntary and will not affect your care in any way.
• We may share your de-identified information with third parties without any further consent or authorization.
• Once collected by Us, your information will be stored with industry standard security safeguards.

WHAT IS A REGISTRY?

A Registry is a collection of information about people who have various diseases or conditions, or who receive various tests or treatments. The Registry holds patient information according to the data security standards of federal and state law.

This Informed Consent provides you with information that you should know and understand before agreeing to add your information to the Registry. Please read this Informed Consent carefully.

WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?

Information (data) will be collected from your health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will collect health, demographic, claims, billing, pharmacy and medical records. All information will be collected from your records of the care you have received in the past ten years, are receiving or will be receiving in the future for so long as you continue to participate in the Registry.

HOW WILL INFORMATION IN THE REGISTRY BE USED?

The purpose of this Registry is to help Us predict, prevent, and treat disease. Information in the Registry may be used for medical, research, commercial, marketing or other business purposes including, but not limited to providing healthcare or care coordination services, communicating with you about diagnostic tests, clinical trials or other healthcare related services that may be of interest based upon your medical history including marketing and promoting our services and the services of third parties, aggregating and analyzing data to understand or improve Our testing, treatment services, and operations, research to predict, prevent and treat disease(s), de-identifying data to create data sets that will be shared with third parties such as medical researchers and drug developers to advance medical treatment, for administrative purposes, and for other legally permissible purposes.

HOW WILL MY HEALTH INFORMATION BE SHARED?

We may share your identifiable information with Our affiliates under common ownership to use for the same purposes for which We may use your information. We may also share your information with third party service providers performing services on our behalf. We may share your information for legal purposes including as we deem necessary to respond to a subpoena, regulation, binding order of a data protection agency, legal process, governmental request or other legal or regulatory process. We may also share your information in business transfers including in connection with a merger, acquisition, the sale of company assets, or in any similar transaction, or to the extent as may be required in the unlikely event of insolvency bankruptcy, or a receivership. Once your information is de-identified is no longer personal information and can be used by Us and shared with third parties for any purposes, including sale to third parties.

HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?

With your authorization, we will collect your historic and future health information when you enroll in the Registry. You may stop participating in the Registry at any time.

WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?

We will comply with the applicable HIPAA standards that protect your health and personal information. However, there is the potential risk your participation in this Registry may expose your information (including health information) stored in the Registry.
There may be other risks that are not known at this time.

WHAT BENEFIT CAN YOU EXPECT?

You may receive a benefit from participation in the Registry if We are able to provide you information about diagnostic tests or clinical studies for which you may be eligible. For research related purposes, you will not receive any direct benefit.

WHAT ARE THE FINANCIAL CONSIDERATIONS?

Cost
There will be no cost to you for your participation in this Registry.
Payment for Participation
You will not be paid for your participation in this Registry or for any future use of the information in the Registry.

VOLUNTARY PARTICIPATION/WITHDRAWAL

Your decision to take part in this Registry is completely voluntary. You are free to choose not to take part in the Registry and may change your mind and withdraw at any time. Your relationship with Us and your care through Us (now or in the future) will not be affected in any way if you withdraw or refuse to participate. You will not lose any benefits to which you are otherwise entitled.

WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?

By clicking Submit on this informed consent form and authorization, you are giving permission for Us to obtain, use and share your information as described above. If you refuse to give permission, you are declining to be in this Registry.
Information that is already in the Registry cannot be removed, deleted or withdrawn.

QUESTIONS

If you have any additional questions, or if you wish to report a problem that may be related to this Registry, Our Privacy Officer can be reached by email at privacy@recoverycoa.com or at 484-803-9655 during business hours.
Do not click Submit on this informed consent form unless you have had a chance to ask questions and have received satisfactory answers to all your questions.

AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION

To enroll in the GENETWORx Registry, you or your legal representative must click Submit on this Authorization. By clicking Submit on this page, you are confirming that you have read the information in the “Informed Consent to Participate in the Medical Record Registry” document and you are voluntarily agreeing to be in the Registry.

By clicking Submit on this Authorization, you authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefits manager, medical facility, health information exchange, health information aggregator or other health care provider that has provided payment, treatment or services to you to release and disclose the following records to GENETWORx to be incorporated into the Registry:

Any and all information (including personal, health, demographic, claims, billing, pharmacy and medical records) created in the ten years prior to the date of this Authorization or at any time after the date of this Authorization for as long as this Authorization remains in effect.

The records provided to the Registry will include the following highly protected information (known as Sensitive PHI)

• Substance abuse records (including alcoholism)
• AIDS or HIV treatment records
• Mental health services (does not include psychotherapy notes)
• Genetic information

By clicking Submit on this Authorization, you authorize GENETWORx to use and share your information in the Registry for medical, research, commercial, marketing or other business purposes including, but not limited to, those described in the Informed Consent.

This Authorization involves the use of a Registry and will remain in effect until you revoke it.
You may change your mind and revoke (take back) the right to use your protected health information at any time. However, even if you revoke this Authorization, the Registry may still maintain, use or disclose information it has already collected about you. If you revoke this Authorization, GENETWORx will no longer collect new information about you for the Registry. To revoke this Authorization, you must email privacy@recoverycoa.com.

I understand that information disclosed to the Registry pursuant to this Authorization may be subject to re-disclosure and may no longer be protected by federal and state law.

By clicking Submit, you are voluntarily agreeing to be in this Registry and to the use and disclosure of your protected health information as described above. Your health information is being released to GENETWORx at your request. You understand that your treatment, payment, enrollment or eligibility for benefits does not depend on whether you click Submit on this Authorization and participate in the Registry.

To manage or change opt in preferences or revoke this Authorization, you must call 844-335-2482.

Upon request, you will be given a signed copy of this Authorization form to keep for your personal records.