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Welcome to Clearity's Treatment Decision Support Program

To receive an initial consultation tailored to your specific situation, please:
  1. Complete this secure and privacy-protected Treatment Decision Support Information form that includes the dates of your cancer diagnosis and treatments. 
  2. Acknowledge that your medical data will be entered into the Clearity Database.
  3. Send us your most recent oncology progress note, your diagnostic and debulking pathology reports, most recent scan report, and tumor testing report (if you have had that testing performed). 
After completing the fields below, please review this form using the navigation bar to determine if you have all the requested medical information at hand. 

Once the medical information has been gathered, this form should take 15-20 minutes to complete.

All of Clearity’s services are provided free of charge

Please Note: There is a Save and Resume option at the top of each page to leave the form and return.

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Thank you for your interest

Thank you for reaching out to Clearity's Treatment Decision Support Program

Currently, we only provide support to individuals who are diagnosed with ovarian, fallopian tube, or primary peritoneal cancer.


If you would like to stay in touch and receive information about Clearity and upcoming events, please fill out the information below.












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Step 1: Complete the Personal Information Sections below. 

Please Note: You can Save and Resume (upper right) during any part of this registration.
Patient Information



















Physician Information









Patient Contact/Caregiver Information:














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Please review this form to determine if you have all the requested medical information at hand. 

If you do not have all information, please click Save and Resume (upper right) to complete this form later.

Once started, this form should take 15-20 minutes to complete.

If you have questions, please contact the Treatment Decision Support team at: patientsupport@clearity.org

Diagnosis Information
















Test Results




Treatment Information

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Additional Questions





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Informed Consent for Clinical and Tumor Molecular Profiling Data


Purpose


In its Treatment Education Program, Clearity provides information about standard treatment options for your clinical situation as well as the latest promising results from drugs in clinical development.  A member of the Clearity scientific team will review your clinical and tumor testing information with you and help you find clinical trials for which you may be eligible, if/when appropriate.

 

Clearity does not provide medical advice about which treatments you should receive. Instead, our staff explain tumor-testing results and standard treatment options for your situation as well as provide potential questions, and other information, that you can discuss with your physician.

 

Clinical Information and Test Results


You have provided us with your clinical information (e.g., clinical history) and will be having the results from the testing of your tumor (or blood) sample sent to us.  That testing was performed to find out if your cancer has certain molecular biomarkers. The biomarkers include chemical materials, such as proteins and RNA, which may cause cancer cells to grow out of control. The biomarkers may also include changes in your DNA, called mutations.  Biomarker test results may help your doctor make decisions about the best treatment options for your ovarian cancer.

 

 

Storage of Your Information in the Clearity Database


To help with your educational discussions with Clearity staff, we will enter the clinical information that you provide to us from your medical records (e.g., surgeries, chemotherapy treatments) into The Clearity Foundation Database.  To enable our search of clinical trials that match the biomarkers in your tumor, we also enter the chemical and genetic information about your tumor samples into the Database.  Your personal information (name, address, medical record number, etc.) and clinical information will be kept confidential in a privacy-protected, securely encrypted place. 

 

The Clearity Foundation keeps your clinical information and tumor molecular profiling results confidential and fully obeys the Health Insurance Portability and Accountability Act (HIPAA). Your information will only be released as directed by you, which would include the healthcare provider (s) or his or her designee, as directed by you (or a person legally authorized to act on your behalf) in writing, or as required by federal and state laws.

 

Possible Risks


The Clearity Foundation takes all reasonable steps to protect confidentiality, but confidentiality cannot be guaranteed.

 

Possible Benefits


Understanding standard of care options, and knowing the molecular profile of your tumor may help you and your doctor make more informed choices about your cancer treatment. However, there is no guaranteed benefit to you from the educational and clinical trial information provided by Clearity staff.


Consent

  • I have read and have access to a copy of this form.
  • I understand the information provided and my questions have been answered.
  • I agree to have my clinical information and tumor testing results incorporated into the Clearity Foundation Database.