Healthcare Diabetes Symposium Packet

HEALTHCARE DIABETES SYMPOSIUM PACKET

Symposium Name:   Symposium Date:   Location:

Participant Information

Emergency Contact

Insurance Information

Medical History — Diabetes Specific

Consent for Onsite Clinical Assessment and Emergency Care

I authorize trained clinical staff and symposium medical volunteers to perform routine assessments related to my diabetes care while I participate in symposium activities. Such assessments may include, but are not limited to, point-of-care glucose testing, blood pressure measurement, basic first aid, and administration of emergency medications when indicated to prevent serious harm. I understand that onsite care is not a substitute for ongoing medical care and that, if necessary, I may be transferred to emergency medical services or a hospital for further evaluation and treatment.

Consent to onsite care:   I understand I may withdraw consent at any time by notifying symposium medical personnel.

HIPAA Authorization and Privacy Acknowledgment

I authorize the disclosure of my protected health information (PHI) to symposium organizers, onsite clinical staff, and designated volunteers for purposes of treatment, emergency care, and symposium administration. This PHI may include medical history, medication lists, glucose results, and immunization status necessary to provide safe participation in symposium activities. I understand that disclosed information will be used only for the purposes stated and that reasonable safeguards will be used to protect my information.

Authorization expiration date:   (If left blank, this authorization expires one year from the signature date.)

Acknowledgment of privacy practices: I acknowledge that I have received, reviewed, or been offered a copy of the symposium privacy practices describing how my health information may be used and disclosed.
Acknowledged:

Media and Educational Materials Release (Optional)

I grant symposium organizers and their authorized agents permission to photograph, record, and use my image, likeness, and non-identifying health information for educational and promotional materials associated with the symposium. I understand that identifiable health information will not be used without separate written authorization.

I consent to media use:

Certification and Authorization

By signing below, I certify that the information I have provided is true and complete to the best of my knowledge. I authorize release of my health information as described above and consent to the limited onsite clinical services necessary to ensure my safety while attending the symposium. I understand that I remain responsible for my ongoing medical care and for follow-up with my personal healthcare provider as needed.

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