Refer potential patients by completing the information below.

*Specifically for the BI LIVERAGE-Cirrhosis 1404-0064 study

STEP 1:

Enter your information below:

DON’T SKIP STEP 3 below!

Name

First Name

Last Name

Email

Practice/Clinic Name:

Clinic Zip Code:

Specialty:

Phone:

(###)

###

####

STEP 2:

Enter patient information below:

Name

First Name

Last Name

Gender:

Date of Birth:

MM

DD

YYYY

Phone Number:

(###)

###

####

Email:

Preferred Contact Method:

Phone

Email

Primary Diagnosis/Condition:

Previously Diagnosed with NASH/MASH?

Yes

No

Currently Under Treatment?

Yes

No

Is the patient aware of this referral?

Yes

No

Any Additional Comments?

STEP 3:

Consent and Authorization

Provider Signature (type out name):

Date:

MM

DD

YYYY

Patient Consent Confirmation:

Patient has provided verbal/written consent to share medical information for research referral purposes.

Patient has NOT provided verbal/written consent to share medical information for research referral purposes.

Data Privacy and Patient Consent Disclaimer:

Privacy & Patient Consent Disclaimer:

By submitting this referral form, the referring provider confirms that the patient has been informed about the purpose of this referral and has provided verbal or written consent to share their personal and medical information with an participating LIVERAGE or LIVERAGE-Cirrhosis research site for the purpose of assessing eligibility for participation in a clinical research study.

All personal health information (PHI) submitted through this form will be handled in compliance with the Health Insurance Portability and Accountability Act (HIPAA) in the United States and the General Data Protection Regulation (GDPR) in the European Union. Patient information will be stored securely and will not be used for any purpose other than clinical trial recruitment and eligibility assessment.

Data Privacy & Security:

• The information provided will be shared only with authorized personnel at the research site and will not be disclosed to third parties without patient consent unless required by law.

• The research site will take appropriate measures to protect patient confidentiality and ensure data security in accordance with regulatory requirements.

• Patients have the right to access, correct, or request deletion of their personal data as permitted by applicable laws.

Consent & Revocation:

• The patient has the right to withdraw their consent at any time without affecting their medical care or relationship with their healthcare provider.

• If the patient wishes to revoke consent or has any questions regarding data use, they may contact support@researchhive.com to request removal of their information.

By submitting this referral, the provider acknowledges that they have obtained appropriate patient consent in accordance with applicable legal and ethical guidelines.