Authorization and Certifications
I hereby authorize and direct my healthcare providers, pharmacies, health insurers, and health plans or programs that provide me healthcare benefits, and their respective staff and service providers (“Healthcare Entities”) to use and disclose the following information (“Personal Information”) about me in their possession to SpringWorks Therapeutics, Inc. (“SpringWorks”) and its representatives, affiliates, contractors, agents, vendors, and partners (collectively “SpringWorks Entities”):
• Information regarding my medical condition and treatment, including relevant diagnoses, prescriptions, and related health information (including fill and refill information);
• Information about my health insurance benefits, including deductibles and out-of-pocket costs; and
• All information about me included in this form.
I understand that the purpose of this disclosure is so that SpringWorks Entities may use and further disclose my Personal Information for the following purposes:
(1) verifying, investigating, coordinating, and resolving insurance coverage or reimbursement inquiries and payment for SpringWorks products
(2) operating, administering, enrolling me in, and/or continuing my participation in the SpringWorks CareConnections program or any other SpringWorks-affiliated patient support services and activities (the “Patient Support Program”) related to my condition or treatment including, but not limited to, financial assistance programs such as commercial copay and/or patient assistance programs, drug coverage verification, patient education services, adherence programs, and disease management support;
(3) coordinating my receipt of and payment for SpringWorks products;
(4) utilizing a third-party financial screening tool (eg, Experian or TransUnion), to determine eligibility for financial assistance or free drug programs;
(5) contacting me about the Patient Support Program (including sending me supplemental educational materials, information, offers and services related to my treatment or my medical condition, or communicating with me to facilitate fulfillment of my prescribed medication[s]);
(6) contacting and providing my Personal Information to Healthcare Entities, patient advocacy organizations, patient assistance programs, copay assistance or similar programs to determine eligibility for coverage and enrollment;
(7) managing the Patient Support Program, including evaluating the effectiveness of the Patient Support Program and for administrative purposes;
(8) de-identifying my Personal Information by aggregating it for research purposes, and data analytics to develop and evaluate products, services, materials, and treatments, and improve the Patient Program; and
(9) as otherwise permitted by law.
I understand that once my Personal Information has been disclosed to the SpringWorks Entities, it may no longer be protected by federal privacy law and could be re-disclosed to others but that the SpringWorks Entities intends to use and disclose my Personal Information received pursuant to this authorization only for the purposes described above or as required by law.
I understand and agree that the pharmacy that is dispensing my Product may receive remuneration from the SpringWorks Entities in exchange for disclosing my Personal Information to the SpringWorks Entities for providing me with support services in connection with the Patient Support Program.
No Impact to Treatment
I understand that I am not required to sign this Authorization and that treatment from my Healthcare Entities, payment for treatment, my access to SpringWorks medications (except for participation in a free drug program), and my eligibility for health insurance benefits are not conditioned upon me signing this Authorization. I understand, however, that if I do not sign this Authorization, I will not be able to receive support services through the Patient Support Program. Participation in the Patient Support Program is voluntary, and services are subject to change. I understand that participation in the Patient Support Program is subject to the terms, conditions, and eligibility criteria available at
www.springworkstxcares.com, and that SpringWorks has the sole discretion to determine Patient Support Program eligibility. I understand that SpringWorks reserves the right to rescind, revoke, or amend any service under any Patient Support Program at any time without notice.
Cancellation
I may cancel this Authorization at any time by calling 844-CARES-55 (844-227-3755) or by requesting such cancellation in writing at SpringWorks Therapeutics c/o Patient Support Services, 150 Hilton Drive, Jeffersonville, IN 47130. Canceling this Authorization will prohibit further use and disclosure of my Personal Information; however, canceling this Authorization will not impact uses and disclosures of my Personal Information that has already happened. I understand that once my Personal Information has been disclosed, federal health information privacy laws may no longer protect my Personal Information from further disclosure. Cancellation of this Authorization ends my participation in the Patient Support Program.
This Authorization will expire five (5) years from the date it is signed or earlier if required by applicable law, unless earlier withdrawn by me. I understand that I am entitled to receive a copy of this signed Authorization.
I understand that my Personal Information is also subject to the SpringWorks privacy policy available at
www.springworkstx.com/privacy-policy.
Fair Credit Reporting Act (FCRA) Certification
I understand that I am providing “written instructions” authorizing SpringWorks and its vendors, under the FCRA, to obtain information from my credit profile or other information from the vendor, solely for the purpose of determining financial qualifications for programs administered by SpringWorks, including the CareConnections Patient Assistance Program. I understand that I must affirmatively agree to these terms in order to proceed in this financial screening process.
