Healthcare Fabry Acknowledgment Form

Healthcare Fabry Acknowledgment Form

I acknowledge that I have been informed about Fabry disease, its genetic basis, the proposed diagnostic tests and/or treatments being recommended by my healthcare provider, and the foreseeable risks, benefits, and alternatives. I understand that information provided to me may include details about enzyme replacement therapy, oral chaperone therapy, infusion or infusion-related reactions, laboratory monitoring, and potential adverse events. By signing below I voluntarily confirm that I have been given the opportunity to ask questions and that those questions have been answered to my satisfaction.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Treatment / Testing Acknowledgment

I understand that testing and/or treatments recommended for Fabry disease may include genetic testing, laboratory monitoring, infusion therapies, or oral therapies. I have been informed of the nature and purpose of the proposed intervention, the expected benefits, the substantial and reasonably foreseeable risks (including but not limited to infusion reactions, hypersensitivity, anaphylaxis, infection, transient worsening of symptoms, and unknown long-term effects), and reasonable alternatives, including no treatment. I further understand that no guarantees have been made regarding the outcome of any test or treatment.

The following statements describe specific acknowledgments. Please mark each box to indicate your understanding and acceptance.

I acknowledge that I have received written and/or verbal information about the proposed test or treatment and its risks and benefits.

I understand that there are potential adverse events and that I should report new or worsening symptoms promptly.

I understand available alternatives to the proposed therapy, including observation and symptomatic treatment, and I have had the opportunity to discuss these alternatives with my provider.

Authorization for Use and Disclosure of Health Information

To facilitate treatment, payment, and care coordination, I authorize my healthcare providers to use and disclose my protected health information related to Fabry testing and treatment, including medical records, laboratory results, genetic testing reports, and treatment response, to third parties as necessary for care, prior authorization, insurance payment, patient support programs, and disease registries. I understand that information disclosed pursuant to this authorization may include genetic information and that such information may be used by a manufacturer or registry consistent with applicable law.

I authorize limited de-identified data to be submitted to a patient registry or clinical database for research and quality improvement purposes.

I understand that I may revoke this authorization at any time by providing written notice to the releasing entity, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. I understand I may request restrictions on certain uses and disclosures, and that such requests will be considered in accordance with applicable law.

I acknowledge receipt (or offer of receipt) of the Notice of Privacy Practices.

Financial Responsibility

I understand that I am financially responsible for charges not covered by my insurance carrier, including co-payments, deductibles, and services denied by my insurer. I authorize my provider to bill my insurance and to obtain payment directly when permitted. I also authorize release of information to determine eligibility for patient assistance programs, if applicable.

Voluntary Consent and Certification

By signing below I certify that I am the patient or authorized legal representative, that I am at least 18 years of age unless signing as a parent or guardian, that I have read or had read to me the information on this form, that the nature and purpose of the proposed care have been explained, and that I consent to the testing and/or treatment described. I understand that I may withdraw consent at any time by notifying my provider in writing, but withdrawal will not affect actions already taken in reliance on my consent.

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