Enrollment Form
PATIENT INFOR MATIO N
Caregiver / Legal Guardian Information
Patient first name
Gender
Address
Date of birth
Patient mi
ddle name Patient last name
First name Middle name Last name
Relationship to patient
Phone number
City
State Zip
Male
Female Other
Phone Type Cell Home Oce Email address
Preferred method
Both
Phone
I confirm the patient has access to a supported iOS device (Apple iPhone or iPad)
Email
I consent to being contacted via text/SMS message
Yes
No
Preferred contact time Morning Aernoon
Evening
Page 1 of 2
Please note: Submiing this enrollment form is not a guarentee of coverage or reimbursement
Page 1 of 2
CAREGIVER & PATIENT AUTHORIZATION AND CONSENT FOR TREATMENT
Caregiver / legal guardian name printed
Relationship to patient
/ /
Signature date
to carry out our legal responsibilities, protect our legal rights, or investigate suspected wrongdoing; and
confidentially in the event of a corporate change in control resulting from, for example, a merger, sale of assets, or bankruptcy.
to enable us to provide personalized treatment for the patient;
to communicate with you regarding enrollment, pricing, prescription information, treatment, or any product recalls or modifications;
to communicate with your healthcare professional to confirm, obtain, or update your child’s prescription for EndeavorRx™, regarding your child’s treatment, and
to help us complete any missing information on this Enrollment Form;
to facilitate any applicable payment for EndeavorRx™; and
if you separately request, so that we may determine your eligibility for our Patient Assistance Program, which may help cover all or part of the cost of treatment.
We need your permission to provide your child with EndeavorRx™ treatment and to use and disclose the information provided on this Enrollment Form and during this
enrollment process (the “Enrollment Information”). This Authorization and Consent agreement (“Authorization”) covers the ways in which Akili Interactive Labs, Inc.
and our partners, such as our call center and data storage partners (together, “Akili,” “us,” “our,” or “we”), may use, exchange, collect, and disclose the Enrollment
Information, including with, from, and to the pharmacy that fills the prescription and your child’s healthcare professional (the “Authorized Parties”).
When you register to use one of Akili’s software apps, you will also be asked to accept our Privacy Policy, which further explains how we collect, use, disclose, and
safeguard your information, and is located here: https://my.akili.care/privacy.
How will your Enrollment Information be used and disclosed?
By signing this Authorization, you give Akili and the Authorized Parties permission to confidentially collect, use, exchange, and disclose Enrollment Information, for
example your and your child’s name, address, diagnosis, DOB, and healthcare professional information, for purposes related to your enrollment with Akili and the
patient’s treatment with EndeavorRx™ such as:
We may send the communications via phone, email, or SMS (unless you have not opted in for, or have opted out of, SMS), including using an automated dialer.
Message and data rates may apply. You may opt out of any SMS messages by responding with “STOP”. To receive help, respond via SMS with “HELP”.
Akili may also use or disclose Enrollment Information:
This form allows you to initiate and
fulfill an EndeavorRx™ prescription.
Please complete and fax all sections of this form to Akili Assist® at 1-866-565-4633 to initiate your patient's prescription for processing.
Once Enrollment Information has been disclosed in any of the ways described herein, federal and state privacy laws may no longer protect such information, but we
will take measures to keep your information confidential.
What if I have additional questions?
Our Akili Assist® team is here to help. Please call 1-844-AKILI-IQ (1-844-254-5447) Monday through Friday between 9:00am and 8:00pm ET, email
info@akiliinteractive.com, or visit AkiliAssist.com
By typing my name and date below, or alternatively writing my name and date below on a hardcopy, I agree that: (i) I am signing this Authorization with an
electronic signature (if typed), or I am signing this Authorization (if written); (ii) I am at least 18 years old; (iii) I am the parent or legal guardian of the patient
identified on this form; (iv) I have read, understand, and agree to the uses and disclosures of Enrollment Information and all provisions described above; and (v) I
authorize Akili and the Authorized Parties to provide the patient identified above with EndeavorRx™ and support services.
Version 4
