Patient Support Program Enrollment and Data Collection Consent
I agree to enroll in the inLighten Patient Support program provided by Insmed and verify that the information in the “Patient Information” section of this form is accurate and complete. I also agree that Insmed and its data processors, affiliates, agents, contractors, and any other person or entity assisting Insmed in the administration of the inLighten Patient Support program (which may include but not be limited to co-pay administrators, fulfillment/logistics partners, and patient educators) may collect, use, and disclose information about me, my finances, and my health, which may include my sensitive data and consumer health data, as listed below (collectively, “My Information”), for the Purposes defined in the Authorization for Us eand Disclosure of My Health Information:
• Individual health conditions, treatment, diseases, or diagnosis;
• Social, psychological, behavioral, and medical interventions;
• Health-related surgeries or procedures;
• Use or purchase of prescribed medication;
• Bodily functions, vital signs, symptoms, or measurements related to health;
• Diagnoses or diagnostic testing, treatment, or medication;
• Data that identifies me as a consumer seeking health care services; and
• Health-related data that have been derived or inferred from the above.
I understand that I am not required to consent to processing of My Information for these purposes. However, I understand that if I do not consent, I will not be able to participate in the inLighten Patient Support program, as collection of My Information is necessary for Insmed to facilitate my participation. I understand I have the right to withdraw my consent to participate in the inLighten Patient Support program at any time. I also understand that, depending on where I live, applicable state law may grant me the right to request restrictions on Insmed’s collection, use, and disclosure of MyInformation. If I withdraw my consent, I understand that the uses and disclosures of My Information previously made in reliance on this Consent will not be deemed invalid. To withdraw my consent to participate in the inLighten Patient Support program or to request restrictions on the collection, use, or disclosure of My Information, I understand that I may call 833-544-4800 or write to Insmed Incorporated, Attn: inLighten Patient Support program, 700 US Highway 202/206, Bridgewater, NJ 08807.