Purpose of this Form: This Consent and Authorization gives OvaScience, Inc., and those acting on its behalf ("OvaScience") permission to use your personal information, including health information, (your "Personal Information") that you disclose in connection with your use of the OvaScience [Patient Assistance Service] (the "Service"). Please read this form carefully and ask any questions that you may have before signing.
I. Use and Disclosure of Personal Information
By signing this form and providing my Personal Information to OvaScience, I consent and authorize OvaScience to provide my information to a provider of advanced IVF procedures using OvaScience technology.
II. Purpose of Consent and Authorization
I request that OvaScience act on my behalf in identifying available providers of advanced IVF procedures; facilitating provider-patient communications, including the exchange of health and administrative information; and other related tasks. [I understand that my Personal Information may be anonymized and used for research purposes as permitted by applicable law and I expressly consent to such uses].
III. OvaScience is Not a Health Care Provider
I understand that OvaScience is not a health care provider and that the Service is limited to assisting me with my pursuit of advanced IVF treatment. OvaScience cannot guarantee that I will qualify for advanced IVF treatment or that any such treatment will be successful. OvaScience cannot and will not provide medical advice or opinions regarding my care, whether I am a potential candidate for treatment or any other service that requires professional licensure or certification. All of my medical questions must be directed to a qualified health care provider.
IV. Health Care Provider Release
In order to maximize the benefit of the Service, I understand that OvaScience must communicate directly with health care providers on my behalf and may receive Personal Information from my health care providers.
V. Limit on Protection of Disclosed Information
I understand that Personal Information used and disclosed in connection with the Service may be re-disclosed to third parties who are not obligated by law to protect it. OvaScience and everyone involved in providing the Service has taken careful steps and is fully committed to protecting the privacy and maintaining the security of my Personal Information, but absolute confidentiality can never be guaranteed.
VI. Revocation of Authorization
I understand that I may terminate the Service and revoke this Consent and Authorization at any time – even after I have signed this form. My revocation will not be effective for Personal Information that I have already disclosed and OvaScience has already used. However, no additional uses or disclosures of my Personal Information will be made following my revocation. I understand that my revocation must be submitted in writing and that I may address my revocation to:
c/o Patient Advocacy
9 Fourth Avenue
Waltham, MA 02451
VII. Cross Border Transfer of Personal Information
I understand that in order to provide the Service, OvaScience may be required to transfer my Personal Information from my country to other countries where the privacy laws are not as comprehensive. I expressly consent to the transfer of my Personal Information as described in this Section VII.