Authorization for the Release of Protected Health Information
I authorize UpScript, LLC to disclose certain protected health information about me, as further described below, to Gelesis, Inc., 500 Boylston Street, Suite 1600 Boston, Massachusetts 02116.
Specifically, I authorize UpScript, LLC to disclose: whether or not I have been give an prescription for Plenity, whether that prescription has been filled, the date(s) on which Plenity prescription(s) have been filled, the amount of Plenity prescribed, any information I provide about previous diagnoses of diabetes, prediabetes or elevated blood sugar, and any information UpScript, LLC may have regarding my experience taking Plenity.
I am providing this authorization to facilitate my participation in a program by Gelesis to examine and evaluate patient experiences with Plenity, so that Plenity can determine my eligibility for its program, my continued participation in the program if selected, and evaluate my experiences with Plenity (if prescribed).
This authorization shall remain valid as long as I continue to participate in the Gelesis Invitation Only Extension Program.
I understand, however, that I may revoke this authorization in writing at any time by providing written notice to UpScript, LLC at 7033 E Greenway Parkway, Suite 310, Scottsdale, AZ 85258. I understand that if I choose to revoke my authorization this will not affect disclosures made pursuant to this authorization before my revocation is received and processed. I also understand that if I fail to provide this authorization or exercise my right to revoke it at a later time, I may not be able to continue to participate in the Gelesis program described above and will not be eligible to receive Plenity at no cost to me.