Healthcare Education Program

HEALTHCARE EDUCATION PROGRAM ENROLLMENT & CONSENT

This Healthcare Education Program Enrollment & Consent form documents enrollment in an instructional program provided by the healthcare facility. Participation is voluntary. Please complete all sections accurately. Information provided will be used for program planning, clinical coordination, and permitted educational evaluation.

Patient Information

Male Female Other

Emergency Contact

Insurance Information (if applicable)

Program Details

Start Date:   Sessions:

In person Online Hybrid

Medical History & Current Status

Consent, Authorizations & Acknowledgements

I, , voluntarily enroll in the program identified above. I acknowledge that staff have explained the nature and purpose of the program, expected activities, and my responsibilities.

Risks and benefits have been discussed; benefits may include improved knowledge and self-management. Potential risks include emotional discomfort, fatigue, or other program-specific risks communicated by staff. I understand I may stop participation at any time without penalty to my ongoing clinical care.

I authorize the limited sharing of relevant medical information for purposes of program participation and evaluation (attendance, progress notes, and outcomes). This authorization does not permit disclosure beyond clinical and program staff except as required by law. Authorization expiration date:

I authorize the program to photograph or record (audio/video) me for training, quality improvement, or educational purposes: Yes No

I consent to program staff contacting my insurer for billing related to program services as needed: Yes No

I understand that participation does not replace individualized medical treatment. I have the right to ask questions and to withdraw this authorization in writing at any time, except to the extent that the program has already acted in reliance on this authorization.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge receipt of the facility's privacy practices and understand how my protected health information may be used in connection with the program. I authorize disclosure of the minimum necessary information to program personnel for coordination and quality improvement.

I acknowledge receipt of the privacy practices and consent to the described uses of my information.

Participant Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that false statements may affect my eligibility to participate. I have had the opportunity to ask questions and have received satisfactory answers.

Yes No

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