Healthcare HealthTree Roundtables

HEALTHTREE ROUNDTABLES PARTICIPANT CONSENT & AUTHORIZATION

Participant Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (Brief)

Information to Be Shared in Roundtable

By participating in HealthTree Roundtables you may voluntarily disclose personal health information to other participants and facilitators. Please indicate the types of information you authorize to be shared in the group setting:

I authorize sharing of my medical history and diagnosis in the roundtable.

I authorize sharing of relevant test results (labs, scans) in summary form.

I authorize sharing of medication and treatment information.

I authorize sharing of other health information described here:

Consent, Acknowledgments, and Authorizations

Participation Consent: I consent to participate voluntarily in HealthTree Roundtables. I understand these sessions are peer group discussions and educational in nature and are not a substitute for professional medical diagnosis or treatment. I accept that facilitators are not providing individualized medical care during roundtables.

Confidentiality and Limits: I understand that participants will be asked to respect confidentiality, but absolute confidentiality cannot be guaranteed. I acknowledge that HealthTree and facilitators are not legally obligated to maintain participant confidentiality to the same extent as a licensed clinician in a treatment setting, and that disclosures of intent to harm self or others, or abuse of a minor or vulnerable adult, may require reporting under applicable law.

Authorization to Disclose Protected Health Information (PHI): I authorize the disclosure of my relevant PHI to other roundtable participants and designated facilitators for the purpose of group discussion, peer support, and educational activities. This authorization includes medical history, treatment information, and medication details as checked above. I understand that information disclosed pursuant to this authorization may be re-disclosed by recipients and may no longer be protected by federal or state privacy laws.

Media Release: I consent to the voluntary recording (audio and/or video) of group sessions only if explicitly announced prior to the session. I understand recordings, if any, will not be made or distributed without separate written permission. I consent or decline recording below.

I consent to audio/video recording when announced and when separate permission is obtained.    I do not consent to audio/video recording.

Voluntary Withdrawal and Revocation: I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation must be submitted in writing to the roundtable facilitator or program administrator. Revocation will not affect disclosures already made under this authorization prior to receipt of the revocation.

Release and Indemnification: To the extent permitted by law, I release and agree to indemnify and hold harmless HealthTree facilitators and sponsoring organizations from claims arising from my participation in roundtables, except for claims resulting from willful misconduct or gross negligence.

HIPAA Acknowledgment: I acknowledge that I have received the program's notice concerning privacy practices and that I understand how my health information will be used and disclosed in connection with roundtable participation.

I acknowledge receipt of privacy practices and authorize disclosures as described in this form.

Authorization Period

This authorization is effective on the date signed and will expire on: . If no expiration date is provided, this authorization will remain in effect until revoked in writing.

Participant Statement and Certification

By signing below I certify that I am the individual named above or the authorized representative of that individual. I have read and understood the contents of this form, I have had the opportunity to ask questions, and I voluntarily consent to participate and authorize the disclosures described herein.

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