HIPAA Authorization for Collection of Demographic Information

Purpose: By signing this form, you agree to allow AspireCURES to collect and store your demographic information, which may include your age, sex, race, ethnicity, zip code, language preference, and other relevant data. This information may be used to match you with potential clinical trials, research studies and/or treatment options.

Use of Information: Your data will only be used for:

  • Clinical trial matching

  • Outreach for research opportunities and matching

  • Treatment options and matching

  • Reporting aggregate statistics for health equity and inclusion

  • Internal operations related to improving patient services

Confidentiality: We are committed to safeguarding your personal information. All collected data will be stored securely and will only be accessed by authorized personnel in accordance with HIPAA regulations.

Your Rights:

  • You may refuse to sign this authorization. If you choose not to sign, we may not be able to provide matching services.

  • You may revoke this authorization at any time by submitting a written request to info@aspirecures.com.

Authorization Duration: This authorization is valid for the term of your matching interest or until revoked in writing.

AspireCURES, LLC Clinical Trial, Research Study & Treatment Options Matching Program

CONSENT TO PARTICIPATE AND WAIVER OF LIABILITY

This Consent and Waiver (the "Agreement") is entered into between the undersigned individual ("Participant") and AspireCURES, LLC ("Company"). Under this agreement, the "Company" is acting as a Recruitment Facilitator.

By signing this Agreement, the Participant voluntarily consents to participate in the Company's Matching Program (the "Program") under the following terms and conditions:

Consent to Collection, Use, and Disclosure of Information:

The Participant authorizes the Company to collect, access, use, and disclose the Participant’s personal, demographic, health, and medical information ("Personal Information") solely for purposes of:

  • Assessing eligibility for clinical trial opportunities, research studies, and treatment options.

  • Matching the Participant with clinical trial opportunities, research studies, and treatment options.

  • Communicating relevant opportunities to the Participant.

The Company will protect Personal Information in accordance with applicable laws, including HIPAA where applicable.

Voluntary Participation and No Guarantee:

Participation is voluntary and does not guarantee:

  • Matching with a clinical trial, research study and/or treatment option(s).

  • Eligibility or enrollment into any clinical trial or research study.

  • Acceptance by trial sponsors or investigators.

No Provision of Medical Advice:

The "Company" does not provide medical advice, diagnosis, or treatment. Participants should consult licensed healthcare providers regarding decisions. The "Company" is not responsible for trial outcomes.

Waiver and Release of Liability:

Participants waive and release the Company from any claims arising from participation in the Program or any clinical trial, research study and/or treatment including consequences arising from participation or non-participation.

Use of De-Identified Information:

Participants consent to the use of de-identified information for clinical trials, research studies, analytics, and program development. AspireCURES, LLC does not guarantee complete privacy if the participant has a relationship with 3rd party.

Withdrawal:

Participants may withdraw at any time by contacting AspireCURES, LLC.

PRIVACY NOTICE FOR PATIENTS

Information We Collect:

  • Personal Identifiers (name, DOB, contact info)

  • Health Information (medical history, diagnoses)

  • Demographic Information (gender, ethnicity, location)

  • Communication Preferences

How We Use Information:

  • Assess clinical trial eligibility, research study eligibility, and potential treatment options

  • Match to clinical trials, research studies, and potential treatment options

  • Communicate about opportunities

  • Improve services using de-identified data

How We Share Information:

  • Clinical trial sponsors and investigators

  • Service providers (under confidentiality agreements)

  • Regulatory authorities as required

  • No sale of personal information

Data Security:

Appropriate safeguards are implemented to protect your information.

Your Rights:

  • The participant has the right to access, correct, or delete your information

  • Withdraw consent

By enrolling in the matching program, you may receive links to other websites. Clicking on one of these links will take you to that website for which AspireCures, LLC has no responsibility. We encourage you to read the privacy statements on all such sites as their policies may be different than ours.

TERMS OF SERVICE

Program Description:

The Program provides informational matching to potential clinical trials, research studies and/or treatment options. Final eligibility and enrollment are determined by third-party sponsors.

No Medical Advice: 

The Program provides information only and does not replace medical consultation.

User Responsibilities:

  • Provide accurate information

  • Comply with laws

  • Acknowledge voluntary participation

Privacy:

Information use is governed by our Privacy Notice.

Intellectual Property:

All Program content is the property of the Company.

Disclaimer of Warranties:

The Program is provided "as is" without warranties.

Limitation of Liability:

Company disclaims liability for damages arising out of participation.

Indemnification:

Participants agree to indemnify the Company from any claims arising from their participation.

Governing Law:

These Terms are governed by the laws of the United States.

Modifications:

AspireCures, LLC reserves the right at any time and without notice to change this policy simply by posting such changes on our site. Any such change will be effective immediately upon posting.

NOTICE OF DATA BREACH POLICY

At AspireCURES, LLC, protecting your personal and health information is a top priority.  AspireCURES, LLC will respond if there is a breach involving your information, as listed below.

What Constitutes a Breach:

A breach occurs when your personal, demographic, or health information is accessed, disclosed, or used in a way that is unauthorized and compromises the security or privacy of your information.

Examples may include:

  • Unauthorized access by employees or third parties

  • Theft or loss of devices containing your information

  • Cyberattacks or hacking incidents

  • Accidental sharing of your information with the wrong recipient

Our Commitment to Notify You:

If we discover a breach involving your unsecured personal or health information, we will notify you as required by applicable federal and state laws.

Notification will occur without unreasonable delay, and no later than:

  • 60 calendar days after discovery of the breach (for breaches involving health information under HIPAA);

  • As otherwise required under state data breach notification laws.

Method of Notification:

We will notify you by one or more of the following methods:

  • Written notice mailed to your last known mailing address

  • Email notification (if you have consented to electronic communications)

  • Public posting or other methods if direct notification is not feasible

Information Included in Breach Notice:

Our notification will include, at a minimum:

  • A description of the breach (what happened and when)

  • A description of the types of information involved

  • Steps you should take to protect yourself from potential harm

  • What we are doing to investigate and mitigate the breach

  • Contact information for you to obtain further information

Steps We Will Take:

In the event of a breach, we will promptly:

  • Investigate the circumstances of the breach

  • Contain and mitigate any harm

  • Notify affected individuals as required

  • Notify regulatory authorities if applicable (e.g., U.S. Department of Health and Human Services for PHI breaches)

  • Review and strengthen our data security practices as needed

Your Rights:

You have the right to:

  • Receive timely notice of any breach involving your unsecured information

  • Receive assistance in understanding any actions you should take to protect yourself

  • Request additional information about the breach investigation

Florida Information Protection Act (FIPA) 

AspireCURES, LLC must comply with federal laws and Florida state data breach laws.

What Is Protected:

Florida protects "Personal Information" — which includes:

  • First name or first initial plus last name and one or more of:

  • Medical history, mental or physical condition, or medical treatment or diagnosis

Notice to Individuals:

The notice will include, as required by Florida state law:

    • The date, estimated date, or date range of the breach

    • A description of the personal information that was accessed or acquired

    • Contact information (email, phone, address)

    • A brief description of the actions taken to investigate, mitigate, and prevent future breaches

    • Advice on how the individual can protect themselves

Effective Date: January 1, 2025

Contact: AspireCURES, LLC 132 Ascend Circle West Melbourne, FL 32904

info@aspirecures.com

AspireCURES, LLC reserves the right to periodically update this Notice.