Referrals - Massive Bio

Provider Referral
Patient Self-Referral

Provider Referral

Please provide your patient’s contact information, and a representative will contact them soon.

Patient Name*

Patient Phone*

Patient has been informed that Massive Bio will be contacting them. YesNo

Referring Physician Name *

Physician Email*

Referring Physician Phone*

Physician Location

By submitting this form, you agree to the Privacy Policy and Terms & Conditions.

For questions, please contact us at support@massivebio.com or 844-627-7246

Patient Self-Referral

Please provide your contact information, and a representative will contact you soon.

Individual’s printed name *

Date of birth *

Email *

Phone number *

Date

Individual’s Signature area *

Alternatively, a legal representative for the individual may sign below:

Name of individual’s representative

Relationship to Patient

Date

Signature of Individual’s Representative

By submitting this form, you agree to the HIPAA release form , Privacy Policy and Terms & Conditions.

For questions, please contact us at support@massivebio.com or 844-627-7246

Authorization to Release and Disclose (HIPAA Agreement).

By signing below, I am authorizing my health care provider to disclose my protected health information (PHI) to Massive Bio and its subcontractor(s). I authorize the release of all medical records, treatment history, medical data, including laboratory test results, tumor measurements, CT scans, MRIs, x-rays, and pathology results, and other clinical information relevant to my disease, other medical conditions that may affect your treatment, information on side effects (adverse events) you may experience, and how these were treated, long-term information about your general health status and the status of your disease, data that may be related to tissue and/or blood samples that may be collected from you; and numbers or codes that will identify you, such as your medical record number. I also authorize Massive Bio to retain and utilize my PHI for 1) research and 2) maintenance of the Massive Bioresearch database, with the exception of records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment for alcohol or drug abuse.

This authorization is being requested by the undersigned individual. I understand and agree to the following:

This authorization is voluntary, and I may refuse to sign it without affecting (1) my ability to obtain treatment from my health care provider, (2) payment for my health care, or (3) my eligibility for health care benefits.
Any information disclosed pursuant to this authorization will be used and disclosed by Massive Bio for me and maybe no longer protected by federal or state law. Massive Bio is not a healthcare provider and no patient-provider relationship is established through the request for any of Massive Bio services, nor by the signature of this authorization.
Treatment decisions are made at the discretion of the treating physician (i.e. primary oncologist) after an independent review of results. Massive Bio is not responsible or liable for these decisions or outcomes from any prescribed diagnostic or treatment interventions.

Frequently Asked Questions

What happens if I do not sign this authorization form?

Borders are a great way to distinguish two elements from one another, but using too many of them can make your design feel busy and cluttered.

If I sign this form, will I automatically be entered into a research study?

No, you cannot be entered into any research study without further discussion and separate consent. After the discussion, you may decide to take part in the research study. At that time, you will be asked to sign a specific research consent form.

What happens if I want to withdraw or revoke (cancel) my authorization?

You can change your mind at any time and withdraw your authorization to allow your personal health information to be used in the research. If this happens, you must withdraw your authorization in writing. Beginning on the date you withdraw your authorization; no new personal health information will be used for research. However, researchers may continue to use the health information that was provided before you withdrew your authorization.

To withdraw your authorization, please contact the person below. He/she will make sure your written request to withdraw your authorization is processed correctly.

Clinical Research Manager RN Phone: 917-336-3319 Fax: 844-742-8837 Email: support@massivebio.com

How long will this authorization last?

If you agree by signing this form that researchers can use your personal health information, this authorization has no expiration date. However, as stated above, you can change your mind and withdraw your authorization at any time.

What are my rights regarding access to my personal health information?

You have the right to refuse to sign this authorization form. You have the right to review and/or copy records of your personal health information kept by Massive Bio. You do not have the right to review and/or copy records, analysis, results, or any other data kept by Massive Bio or other researchers associated with any research study derived from this authorization.

I agree that my personal health information may be used for any and all purposes described in this form.