We need the following information from you to provide you support. We will use this information to provide support and to verify your identity. Your privacy is important to us. Please see our Privacy Policy to learn more about how we protect your personal information.

Please read and then click the link below to sign and submit your form through DocuSign—a trusted and secure eSignature solution. Once complete, you will automatically be returned to KIMMTRAKCONNECT.com.

I hereby authorize my healthcare providers, my health insurance carriers, and my pharmacies with information related to or arising from my treatment as contemplated hereunder (collectively, the “Disclosing Parties”) to use and disclose my individually identifiable health information, including my medical records, insurance coverage information, and my name, address, and telephone number, to Immunocore Ltd., its affiliates, agents, representatives, and service providers, including those authorized by Immunocore to provide drug support and to distribute indigent care drugs (together, “Immunocore”), for the following purposes: (1) to establish eligibility for benefits and coverage benefits information; (2) to communicate with my healthcare providers and me about my treatment or condition and related products relevant to receiving treatment for my condition; (3) to facilitate my participation in the Program, if determined eligible, including, but not limited to, the provision of products, supplies, or services by a third party including, but not limited to, infusion centers; (4) to register me in any applicable product registration program required for my treatment; (5) to enroll me in eligible patient support programs offered by KIMMTRAK CONNECT and/or Immunocore, including nursing or patient access support services; and (6) to assist in the general administration of the Program and conduct any additional services related to the Program, including, but not limited to, measuring Program performance and making Program improvements.

I understand that Immunocore, as well as the Disclosing Parties, cannot require me, as a condition of having access to prescription medications, treatment, or other care, to sign this Authorization, but the services offered by KIMMTRAK CONNECT may be limited or unavailable without it. I understand that I am entitled to a copy of this Authorization.

I understand that Immunocore is not subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and that upon the disclosure of information to Immunocore pursuant to this Authorization, such information is no longer subject to privacy protections under HIPAA and may be subject to redisclosure. However, Immunocore has agreed to use and disclose my information only for purposes of operating the KIMMTRAK CONNECT program or as otherwise required by law. I understand that I may revoke this Authorization at any time by mailing a signed letter requesting such cancellation to KIMMTRAK CONNECT (include address for service provider), but that this revocation will not apply to any information used or disclosed by the Disclosing Parties based on this Authorization before they are notified that I have cancelled it. Unless required by state law, this Authorization is valid until the conclusion of my enrollment in the Program or the date I am notified I am ineligible for the Program, whichever occurs sooner. A photocopy of this Authorization will be treated in the same manner as the original. You have a right to a copy of this Authorization. This form does not impact your ability to access your medical records under state and federal law.