Optional Authorization to Disclose Protected Health Information to Researchers

Version: 19-Mar-2024

This Authorization to Disclose Protected Health Information to Researchers ("Authorization") is effective between you (the “Contributor”), and Geno.Me ("Company"). This Authorization is optional and separate from the authorization set forth in the Geno.Me Terms of Service (“TOS”).

You can agree to this Authorization by typing in your full name and by clicking to accept or agree to “I would like to be contacted if I am eligible to participate in clinical research. I agree to the Optional Authorization to Disclose PHI to Researchers.”, (1) where this option is made available to you by Geno.Me during Contributor Account Signup; or by (2) where this option is made available to you by Geno.Me within your Contributor Account Settings. In either case, you acknowledge and agree that typing in your full name constitutes a valid e-signature and that your Authorization will be effective from that point onwards until revoked by you in accordance with Section 4.

1. Purpose of Authorization: The purpose of this Authorization is to authorize the Company to disclose the Contributor's protected health information ("PHI") to third party researchers ("Researchers") for the purpose of determining the Contributor's eligibility to participate in additional research, such as clinical trials.

2. Disclosure of PHI: If the Contributor accepts the Authorization, the Company may disclose the Contributor's PHI and/or Contributor’s Account Profile information to Researchers. The PHI that may be used and/or disclosed are the clinical summary, which includes but is not limited to consultation notes, discharge summary notes, history & physical, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes, and progress notes. Your Contributor Account Profile information that may be used and/or disclosed are the First Name, Last Name, Phone number, Email, and Physical Address. The PHI disclosed will be limited to the information necessary to determine the Contributor's eligibility for additional research, such as clinical trials.

3. De-identification of PHI: Unless this Authorization is provided, the Contributor's PHI will remain de-identified in any datasets purchased by Researchers. If this Authorization is provided, the Contributor's PHI may be disclosed for the specific Researchers to whom this Authorization applies.

4. Revocation of Authorization: The Contributor may revoke this Authorization at any time by providing written notice to the Company or by opting out through the platform. You can opt out through the platform by deselecting that you accept or agree to “I would like to be contacted if I am eligible to participate in clinical research. I agree to the Optional Authorization to Disclose PHI to Researchers.”, where this option is made available to you by Geno.Me within your Contributor Account Settings. Opting out may take up to 48 hours to go into effect. Upon receipt of such revocation, the Company will cease to disclose the Contributor's PHI to Researchers from that point onwards. Please note that Researchers may continue to have access to your information in datasets purchased by Researchers prior to your revocation of Authorization.

5. Relationship with Researchers: Upon disclosure of the Contributor's PHI to Researchers, the relationship between the Contributor and the Company’s involvement with determining your clinical trial eligibility will end. The Contributor may be contacted directly by Researchers if eligible to participate in additional research, such as clinical trials. The relationship between the Contributor and the Researchers will be governed by separate agreements and consents between those parties. The information disclosed per this Authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA.

6. Understanding and Agreement: By accepting the Authorization, the Contributor acknowledges that the Contributor has read and understands this Authorization and agrees to its terms.

PLEASE REVIEW THIS AUTHORIZATION CAREFULLY. If you have any questions, please contact the Company via email at support@yourgeno.me before accepting. Your PHI is protected by law and you have the right to keep your PHI private. If you do not wish for your PHI to be disclosed to Researchers to be contacted if you are eligible to participate in additional research, such as clinical trials, do not accept this Authorization.