Cutaquig® ProCare

Patient Consent


The ProCare® Patient Support Program (the “Program”) is sponsored by Octapharma Canada and it has contracted with multiple Administrators to provide designated services (“Program Administrator(s)”) depending on the applicable Octapharma products or services and the medical conditions for which they are indicated.

By signing this authorization, I agree and consent to allow Octapharma, its designated Program Administrator, and Providers (defined below) to collect my protected health information, including personal information relating to my medical condition, treatment, care management, and insurance, as well as all information provided on this form and any prescription (“Information”), and share information with my Healthcare Providers and their staff, blood bank(s),  insurance companies, or other healthcare and service providers (collectively, my “Providers”) as necessary to provide me with Services under this Program. I understand that I may refuse to sign this Authorization and that refusing to sign this Authorization will not change the way my physician, health insurance, and other providers treat my condition. I also understand that if I do not sign this Authorization, I will not be able to receive ProCare Program-specific products, supplies, or services. 

I understand and consent to my Providers, the designated Program Administrator and PSP Program Personnel (“Program Personnel”) collecting, using, disclosing amongst each other, and storing my information for the purposes of determining my eligibility for the Program, conducting Programrelated activities and delivering Program services to me, and I authorize Program Administrator to contact me by mail, telephone, text message, or e-mail for provision of Services. I understand that the Program Administrators may monitor or record telephone calls for mutual protection.

I understand my Personal Health Information may be anonymized and aggregated with other patients’ information by the Program Administrator and Providers and shared with Octapharma Canada Inc., its affiliates and their representatives, agents, and contractors (collectively, the “Company”) in connection with the Company’s provision of products, supplies, or service to report on, assess, audit, monitor, improve and/or evaluate the Program. Such information may be used for data analytics, economic analysis and to identify trends such as product utilization, adherence, patient outcomes, and correlate with external health information databases. I understand that the Program Administrator may exchange data with the Company for purposes of adverse event reporting to Health Canada. The Program Administrator will store my information in a secure and confidential database. Access to the database will be restricted to authorized employees of the Program Administrator and Providers.  Program Administrators and Providers employ reasonable physical, technological and administrative safeguards to protect against unauthorized access, disclosure, use, modification or copying. I understand that my information may be collected, used, disclosed and/or stored outside of my province or territory or country, that the laws of those countries regarding privacy may be less stringent than the laws of Canada and its provinces, and that governments, courts or law enforcement or regulatory agencies in those jurisdictions may be able to obtain disclosure of that personal information through the local laws. 

I understand that federal and provincial privacy laws require the Program Administrators and Providers to protect my privacy by requiring that they use and disclose my personal information only for the purposes described above or as required by law. No party shall use my Information for any other purpose unless required or permitted by law, or unless they first obtain my consent or the information that identifies me directly (such as my name) is first removed. I understand that I have the right to request access to my information in the Program Administrators’ possession or control, which includes the right to amend that information and to receive an account of how it has been used and a list of the organizations to whom it has been disclosed.  I understand that I may cancel this Authorization at any time by sending a written notice of revocation to the Program Administrator identified below. I understand that such revocation will not apply to any information already used or disclosed through this Authorization. I understand that once anonymized and aggregated and disclosed to the Company, my Information disclosed under this Authorization may no longer be protected by privacy laws. This Authorization will be in effect for the duration of the period where Service is being requested and provided and for the duration required by law after the end of such Service. I am entitled to a copy of this document.

The parties acknowledge that they require that this Agreement be drawn up in the English language only. Les parties reconnaissent qu’elles ont exigé que la présente convention soit rédigé en langue anglaise seulement. 

By signing the front of this form, I acknowledge that I read, understand and agree to these terms and knowingly and voluntarily authorize and consent to the collection, use, disclosure and storage of my Information in connection with the Program as described in this Authorization. I understand that the Administrator(s) may change without notice and I agree that the consent I provide herein shall also apply to any other Program Administrator(s).

Program Administrator for Octapharma is one or more entities that run and administer all or part of the Program including Inviva McKesson Pharma Care Network Corporation (INVIVA), 2300 Meadowvale Blvd, Mississauga, ON L5N 5P9 and its affiliates and/or other third-party Providers appointed by Company for the provision of services under this program.


Phone Number: 1(855) 310-5120| Fax Number: 1 (833) 358-9153|Email:

Health care Providers include, without limitation, doctors, nurses, blook bank staff and health insurers.

Services may include assessing eligibility for insurance benefits; enrollment in the Procare program; communication including contacting me directly to facilitate access to medication and supplies;

Confidential when completed