Not an acutal patient.

Are you or your loved one receiving prescription treatment for Parkinson’s disease-related hallucinations or delusions and would like to share your experience?

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Not all candidates will be selected. If not selected, there may be opportunities for you to participate in our Ambassador Program in the future.

I am interested in discussing possible speaking opportunities, including opportunities to describe my experience to others and provide testimonials about living with hallucinations and delusions associated with Parkinson’s disease and/or my treatment experience.I am interested in discussing possible speaking opportunities, including opportunities to describe my experience to others and provide testimonials about residing with or caring for someone (the “patient”) with hallucinations and delusions associated with Parkinson’s disease and/or the patient’s treatment experience.

I understand that Acadia Pharmaceuticals Inc. ("Acadia"), and its Project Partners, will collect and process information about me and the patient, including health-related information, to consider my potential participation in the Journey Ambassador Program, and may contact me regarding my interest in the program.

I understand I can choose at any time to opt-out of this role as potential spokesperson by clicking here or sending a notice of revocation Acadia General Counsel, Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA 92130. However, I understand that my revocation shall not be effective with respect to any contact made by or discussions with Acadia or its Project Partners in reliance upon this authorization prior to my revocation.

I understand that this authorization is voluntary and that I may refuse to sign this authorization.

I understand that my treatment, payment, enrollment, or eligibility for benefits or medication is not conditioned on whether or not I sign this authorization.I understand that the patient’s treatment, payment, enrollment, or eligibility for benefits or medication is not conditioned on whether or not I sign this authorization.

I understand if I do not consent, I will not be able to participate in Acadia’s Journey Ambassador Program, as collection and disclosure of my personal information and the patient’s personal and/or health-related information is necessary for Acadia and/or its Project Partners to facilitate my potential participation.

I fully represent and warrant that I have obtained the appropriate consent(s) (whether via direct consent from the patient, power of attorney or otherwise) to discuss the patient’s personal and/or health-related information with Acadia or its Project Partners. I understand that information disclosed in connection with this authorization and/or in future discussions with Acadia or its Project Partners may be subject to re-disclosure and may no longer be protected under the terms of this authorization or by federal privacy regulations. I agree that when I provide this information about myself or the patient, Acadia and its data processors may collect and process this personal and/or health-related information about the patient which may include:

individual health conditions, treatment, diseases, or diagnosis;
use or purchase of prescribed medication;
symptoms related to health;
diagnoses or diagnostic testing, treatment, or medication; and
health-related data that have been derived or inferred from the above

Furthermore, I understand and agree that should I participate in the Journey Ambassador Program, Acadia and its data processors will process information about me, including health-related information, to facilitate my participation in the program. Further, I, as applicable, will be required to execute additional consents and releases including but not limited to releases associated with HIPAA, my appearances and other uses by Acadia.

I fully represent and warrant that I have obtained the appropriate consent(s) (whether via direct consent from the patient, power of attorney or otherwise) to discuss the patient’s personal and/or health-related information with Acadia or its Project Partners. I understand that information disclosed in connection with this authorization and/or in future discussions with Acadia or its Project Partners may be subject to re-disclosure by Acadia and may no longer be protected under the terms of this authorization or by federal privacy regulations. I agree that when I provide this information about myself or the patient, Acadia and its data processors may collect and process this personal and/or health-related information about the patient which may include:

individual health conditions, treatment, diseases, or diagnosis;
use or purchase of prescribed medication;
symptoms related to health;
diagnoses or diagnostic testing, treatment, or medication; and
health-related data that have been derived or inferred from the above

Furthermore, I understand and agree that should I participate in the Journey Ambassador Program, Acadia and its data processors will process information about me and the patient, including health-related information, to facilitate my participation in the program. Further, I, and the patient, as applicable, will be required to execute additional consents and releases including but not limited to releases associated with HIPAA, my appearances and other uses by Acadia.

I understand that this authorization will remain in effect unless otherwise revoked by me.

I am 18 years of age and have full legal authority to enter into this Agreement.

I am/was the caregiver of an individual diagnosed with hallucinations and delusions associated with Parkinson’s disease and I agree that I have their permission to submit information about them to Acadia and/or their Project Partners and provide the authorization on this form on their behalf.

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Thank you for your submission.

Thank you for expressing interest in sharing your story. A representative of our Ambassador Program will be reaching out to gather additional information. Not all candidates will be selected.

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