PTC Cares DMD Patient Consent

I hereby direct my healthcare providers and health plans to disclose my protected health information related to my health conditions, diagnosis, treatment, and use or potential use of EMFLAZA® (deflazacort) and any inferences that may be drawn from this information (my “PHI”) to PTC Therapeutics US, Inc. and its affiliates, agents and contractors (together “PTC”) including, but not limited to, PTC’s specialty pharmacy partners. This direction for disclosure of my PHI as set forth in this form is made pursuant to 45 CFR § 164.524.

I understand and agree that PTC and my pharmacies or designated treatment center may use and process my PHI—which when managed by PTC may be considered to be Sensitive Data and/or Consumer Health Data under the laws of some states—to enroll me in the PTC Cares™ Program, which includes the following services, which I’ve requested (the “PTC Cares™ Program” or “Program”): 1) determining my benefit eligibility for EMFLAZA® (deflazacort); 2) communicating with my healthcare providers and health plans about benefit, coverage and medical care; 3) providing me with support services for EMFLAZA® (deflazacort); and 4) to contact me, leave me messages, and/or provide me with information or materials related to EMFLAZA® (deflazacort), my relevant medical conditions, and/or the Program, which may include patient services such as education, training, nurse, and pharmacy support. To the extent permitted by local regulations, the Program may be utilizing artificial intelligence (AI) to increase quality, to expedite the review process, and to improve user experience. All AI generated content has been reviewed and approved by the Program team.

I further understand that I may decide not to issue this Direction or sign this Consent and that my refusal will have no impact on my eligibility to receive health plan benefits or treatments from my healthcare providers, but I will not have access to support services from the PTC Cares™ Program. I understand that I may terminate this direction to my healthcare providers to disclose my PHI and/or revoke my consent for the continued collection and processing of my Sensitive Data/Consumer Health Data in connection with the Program, at any time by submitting a written notice to PTC Therapeutics via fax to 1‑908‑222‑7231 or by mail to PTC Therapeutics. Attention: Compliance Officer, PTC Therapeutics, 500 Warren Corporate Center Drive, Warren, NJ 07059. I understand that my termination/revocation will not have a retroactive effect on any collection or processing activities which PTC took before it received my termination/revocation and that my termination/revocation will mean that I will no longer receive support services from the Program. This Direction and Consent will expire 10 years from the date it is signed by me. I understand that my pharmacy may receive remuneration in exchange for sharing and using my information pursuant to this Direction and Consent. I understand I can access PTC’s Privacy Statement and Consumer Health Data Statement at PTCBio.com, which also includes a description of my privacy rights. California residents can go here. The personal, insurance and information I have provided on this form are complete and accurate to the best of my knowledge. I will update my information promptly if any of the information reflected on this form changes by contacting PTC Cares™ at 1‑844‑478‑2227.