Opt-Out Request: Third-Party Use of De-Identified Data

As outlined in the Notice of Privacy Practices, Tempus AI and its affiliates, including Ambry Genetics (collectively “we”), may create de-identified data from your Protected Health Information (“PHI”) pursuant to regulations set forth in the Health Insurance Portability and Accountability Act (“HIPAA”). Creating de-identified data is a common and long-established way to advance healthcare innovation and means that identifiers that can be reasonably used to identify you will be removed. We maintain a database of de-identified health data from many patients, including de-identified DNA and RNA data, that is used to facilitate future health care discoveries.

De-identified data may be used and shared with third parties like academic researchers, universities, hospitals, laboratories, and life sciences and other companies, in accordance with applicable laws. These third parties may use the de-identified data for activities such as researching the causes of disease, developing new drugs and therapies, or helping pay for the cost of healthcare.

If you do not wish for your de-identified data to be shared with third parties for the purposes explained above, please complete this form.

Please note the following:

Your request to restrict third party use of de-identified data will apply from the date we process your request.
The patient or a valid legally authorized representative of the patient must complete the form in order for the request to be processed.
The demographic fields below are required in order for us to process your request and match the request to your test order(s) and any associated data.
We may be unable to honor your request if we cannot match the information you provide to data in our system. We cannot honor requests that are received before a test order is created.
We may retain a record of your request as required by applicable law.

Please contact optout@tempus.com with questions related to this request.

Patient First Name *

First Name

Patient Middle Name

Middle Name

Patient Last Name *

Last Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Capacity in which you interacted with Tempus or its affiliates, including Ambry Genetics:

Who is completing this form?*

PatientPatient's Legally Authorized Representative

By signing and submitting this form I request that Tempus and its affiliates, including Ambry genetics, restrict the use of [my] de-identified genetic information by third parties to facilitate future health care discoveries. I understand that Tempus and its affiliates will honor my request to the extent they are able to match the information I have provided with data in their systems. I understand that this request only applies from the date it is processed; it does not apply retroactively to de-identified data that was created prior to the date of this request.

I certify that I have the right as the above-named patient’s Legally Authorized Personal Representative to make this request on the patient’s behalf. I request, on behalf of the above-named patient, that Tempus and its affiliates, including Ambry Genetics, restrict the use of the patient’s de-identified genetic information by third parties to facilitate future health care discoveries. I understand that Tempus and its affiliates will honor the request to the extent they are able to match the information I have provided with data in their systems. I understand that this request only applies from the date it is processed; it does not apply retroactively to de-identified data that was created prior to the date of this request.

Relationship to patient*

Signature*

Date of Signature*

Date

Opt-Out Request: Third-Party Use of De-Identified Data

Acknowledgment and Signature