Warning: Do not agree to anything or sign anydocument with DePuy unless you talk to a DePuy failed hip attorney first. call 1-855-HIPS-911
Patient Consent Form
(for disclosure of records)
DEPUY ASR™ HIP RESURFACING SYSTEM AND
ASR™ XL ACETABULAR SYSTEM
Patient Name:
Patient Address:
Patient Date of Birth:
Information about you and your health is sensitive and confidential and normally will not be disclosed to anyone outside the hospital without your express consent, or at your request.
In the context of the review it is important for the manufacturer of the DePuy ASR™ Hip Resurfacing System and ASR™ XL Acetabular System (“ASR Products”), DePuy International Limited, to be kept fully informed regarding the review process and, in particular, that they be advised of any cases of implant failure or otherwise.
This form should be returned to:
DePuy International Limited
c/o [INSERT LOCAL CRAWFORD OFFICE ADDRESS]
1. I consent to the following being provided to DePuy International Limited of St Anthony’s Road, Leeds, LS11 8DT, United Kingdom:
i. All my medical records and x-rays relating to my original implant surgery by ______________ of an ASR Product on/or about ____________, to include but not be limited to:
Discharge Summary, physician progress notes; physician orders, operative/procedure records and reports; emergency room record, (if applicable); radiographs; product code and lot number of components used, and all records relating to the surgery and all follow up visits and records.
ii. All such medical records and x-rays relating to my subsequent revision surgery by _________________ that occurred in/or about ____________.
iii. The ex-planted ASR product component(s), if available, in respect of both my original implant surgery and subsequent revision surgery, to enable DePuy International Limited to carry out inspection of such components.
2. I understand that the above information and my ASR Product component(s) will be reviewed by or on behalf of DePuy International Limited in order to analyse my experience of and learn more about the ASR Hip product and ascertain whether certain costs related to medical treatment associated with the recall of the ASR Hip product are eligible for reimbursement.
3. I confirm that the purpose of this consent form has been fully explained to me. I have had the opportunity to ask questions about the above and my questions have been answered to my satisfaction.
4. I consent to DePuy International Limited using my personal information collected by this review for analysis. I also consent to this information being collected by or passed, whether within the EU or otherwise, to any affiliated entities of DePuy International Limited (including but not limited to DePuy International Limited’s sister company DePuy Orthopaedics, Inc. of Warsaw, Indiana, USA), and any service providers who are working under contract to DePuy International Limited or its affiliated entities to assist with the evaluation and review described above, and all of whom will agree equally to preserve the confidentiality of the personal information.
_____________
Signature of Patient Date
If you are signing on behalf of a patient, your signature below evidences your confirmation that you have the authority to sign this form on behalf of the patient referred to above.
___________________________________________ _____________
Signature of Patient’s representative Date
Please note that data protection laws in some countries (including the US) to which your information may be transferred under this consent may not be as protective as the equivalent laws in the EU. Please also note that you have the right to access the personal data held about you. To obtain a copy of the personal information, please write to ASR Enquires (Legal Department) at DePuy International Limited at St Anthony's Road, Leeds LS11 8DT. We want to make sure your personal information is accurate and up to date. You may therefore ask us to correct or remove any information you think is inaccurate.
All material contained in this site is for informational purposes only and is not meant to take the place of a licensed lawyer. Attempting to use this material to help yourself may result in irreparable harm to your case. Please consult a License Florida lawyer for help. Examples including case law, rules of procedure and satutory law are for demonstrative purposes and may not be Florida Specific. No attorney client relationship is formed unless we accept your case and you sign a contract.
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