Patient authorization and notice of release of information
The adveva program is sponsored and offered by EMD Serono, a division of EMD Inc., to support patients who are taking MAVENCLAD (the “Program”). The Program is administered by EMD Serono and a third-party service provider and their agents and affiliates (collectively, “Program Administrators”).
In order to enrol you in the Program, your healthcare professional (“HCP”) has provided the Program with certain information about you, as outlined on the Enrolment and Prescription Form, including your personal information (name, gender, age, address, telephone number, email) and personal health information (medical information as it affects your therapy and prescription reimbursement) (collectively, your “Information”).
The Program will collect, use, disclose and store your Information to provide you with the following services (“Program Services”):
Please note that enrolment in the Program may allow access to web-based data by HCPs and Program Administrators.
By authorizing the submission of the adveva enrolment form, you consented to the collection, use and disclosure of your Information by the Program Administrators for administration of the Program and the provision of Program Services, and as required or permitted by law. If you have questions regarding the Program’s privacy policies or practices, you may contact us by calling 1-888-737-6668 or visiting emdserono.ca. You also understand that the Program Administrators may contact you in connection with administration of the Program and provision of Program Services, and you agree to be contacted now and in the future by the Program Administrators regarding the Program, your condition and/or your MAVENCLAD prescription.
In addition, you authorize the Program to obtain further information from your prescribing physician and health insurance company as deemed necessary to ensure the accuracy and completeness of your Information and to administer the Program, and that such further information may include personal information and/or personal health information.
You understand that any financial assistance provided to you as a result of your enrolment in the Program may be reportable income to public or private payers or government agencies. You understand that you are solely responsible for any such reporting as well as ensuring compliance with accepting such financial assistance.
Use and disclosure of your Information
The Program will keep the Information that you provide confidential and will use it only for the purposes of providing you with Program Services and information about the Program. From time to time, the Program may need to disclose certain Information to a third party who is involved in delivering Program Services. This may include, for example, a dispensing pharmacist, reimbursement navigator, field nurse services or an insurer. The Program will limit the amount of Information disclosed to only that Information required in order to deliver the Program Services to you. The Program may de-identify your Information for use such as performing research, education, business analytics and other commercial purposes, including by combining your Information with other data for such analyses. In such circumstances, your Information will not be shared outside of the Program in any way that allows you to be identified. All Information collected and recorded in the Program will be treated and maintained by Program Administrators in compliance with applicable privacy and health privacy legislation. Your Information may be collected, used and disclosed and/or stored outside of your province/territory or country, and the privacy laws of those jurisdictions may be less stringent than the laws of Canada and/or your home province/territory. Your Information will be maintained for as long as the Program is in operation and as may be required thereafter in order to meet legal requirements for maintaining patient records. For more information or to address any additional questions, please contact the Program to speak with the privacy officer. Calls may be monitored and recorded for quality assurance or training purposes.
You can withdraw your consent at any time. If you choose to withdraw consent to the Program, please be aware that you may be ineligible for Program Services, including patient support and reimbursement assistance, from the date of withdrawal.
If you have any questions, please feel free to contact the Program for more information. To obtain information about the Program’s privacy policies and practices, please contact the Program’s privacy officer at 1-888-737-6668 or visit emdserono.ca.