Healthcare Food Waste Program

Healthcare Food Waste Program — Enrollment & Consent Form

Program Identification

Facility Name:

Program Location / Unit:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Dietary Information

Program Participation & Consent

Purpose: The Healthcare Food Waste Program collects post-consumer and pre-consumer food materials generated in the course of care for diversion to composting, anaerobic digestion, or other approved organic recovery processes. Participation will not affect patient care decisions or billing.

I authorize the Facility and its authorized agents to collect, transport, store and process food waste generated in association with my care. I understand accepted materials include uneaten prepared food, plate scrapings, trimmings of edible food, and compostable utensils where provided. Excluded materials include sharps, infectious human tissue, bodily fluids in bulk, pressurized containers, and non-food solid waste. I will follow program instructions for segregation and containment.

Infection Control and Safety: The Facility and Program require adherence to infection control procedures. I understand that any food waste that is visibly contaminated with infectious bodily fluids or regulated medical waste will not be accepted and will be handled according to applicable medical waste protocols. I agree to comply with posted and communicated handling instructions for trays, collection containers, and labeling.

Risks and Benefits: I understand benefits include reduced environmental burden and potential community reuse. I acknowledge there are minimal risks associated with handling and transport of organic waste; the Facility will exercise commercially reasonable measures to mitigate risk. I release the Facility and its agents from liability for routine collection activities except in cases of gross negligence or willful misconduct.

  I consent to diversion of my food waste for composting or anaerobic digestion.

  I consent to use of de-identified program data related to my participation for quality improvement and aggregate research.

  I consent to be contacted by program staff regarding handling, safety, or program logistics at the phone/email provided above.

Privacy, Data Use & HIPAA Authorization

I authorize the release of my relevant medical and dietary information to the Program and its contracted agents solely for the purpose of safe segregation, handling and processing of food waste and for meeting regulatory and safety obligations. This authorization includes dietary orders, food allergies, texture modifications and infection control flags necessary to reduce risk in handling and processing.

I understand that protected health information disclosed under this authorization may be re-disclosed by recipients and may no longer be protected by federal privacy rules, except where re-disclosure is prohibited by law. The Facility will maintain reasonable safeguards to protect individually identifiable information and will limit uses to those described herein.

Revocation, Withdrawal, and Liability

Right to Withdraw: I may revoke or withdraw this authorization at any time by submitting written notice to the Program Coordinator. Withdrawal will not affect actions already taken in reliance on this authorization prior to receipt of revocation.

Liability and Indemnification: Except for injuries or losses directly caused by the Facility's gross negligence or willful misconduct, I agree to release and hold harmless the Facility, its employees and authorized agents from liability arising from collection, transport, processing or reuse of my food waste. I agree to indemnify the Facility for third-party claims arising from my failure to follow segregation or containment instructions.

Operational Acknowledgment

I acknowledge that the Program provides designated collection containers and instructions. I agree to:

1. Segregate accepted food waste items as directed.
2. Not place excluded items (sharps, bulk bodily fluids, human tissue) in program containers.
3. Inform staff of any infection control or dietary precautions affecting collection.

Initials:

Acknowledgment & Signature

By signing below I certify that I have read and understand the terms of participation in the Healthcare Food Waste Program, that the information I have provided is true to the best of my knowledge, and that I authorize the uses and disclosures described in this document.

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