CureDuchenne Cares Registry Header

Please register and provide information about your child. This is a secure website.

Please call CureDuchenne at (949) 872-2552 with any questions.

 

Thank you for registering your loved one on the CureDuchenne Patient Registry. If you have any questions, please contact our office at (949) 872-2552.

*1.  


 

authorize Cure Duchenne to disclose to pharmaceutical companies in the Duchenne space the information contained in the Patient Registry form.

 

The purpose of the disclosure authorized herein is to assist pharmaceutical companies in accessing patients when pharmaceutical treatments become available for Duchenne patients.

 

I understand that my records may be protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164 or similar state rules.  I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may contact me about products or services.

 

I also understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it, and that in any event this authorization expires automatically as follows:

*2.
Question - Required - (Specify the date upon which this authorization expires)




 

Should I decide to revoke this authorization prior to its expiration, I understand that I must do so in writing to the following address: 1400 Quail Street, Suite 110, Newport Beach, California 92660, Attn: Privacy Officer.

 

I understand that the covered entity seeking this authorization is not conditioning treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

 

I understand that I am entitled to receive a copy of this authorization after it is signed.

 

All items on this form have been completed and any questions about this form have been answered.

 

DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM.  DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR ABILITY TO UNDERSTAND IT.

 

Patient or Parent/Guardian of Patient:

*3.  


*4.
Question - Required - Today's Date




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