Healthcare Management Fundamentals

HEALTHCARE MANAGEMENT FUNDAMENTALS — ENROLLMENT, CONSENT, AND AUTHORIZATION

This form registers the participant for the Healthcare Management Fundamentals program and documents participant information, medical accommodations, consent for use of protected health information for educational purposes, and acknowledgments of policies and training requirements. Completion of this form is required for enrollment and for the program to maintain training records in accordance with applicable privacy and institutional policies.

Participant Information

Date of Birth:    Gender: Female   Male   Other/Prefer to self-describe

Employment and Program Details

Program Start Date:    Program Location:

Insurance & Administrative Information

Medical History & Accommodations

Consent, Authorization, and Acknowledgments

I hereby enroll in the Healthcare Management Fundamentals program. I understand that the program includes classroom instruction, case analysis, simulations, skills assessments, and may include discussion or review of clinical scenarios that contain protected health information. I authorize the program administrators and designated staff to use and disclose my protected health information (PHI) to the extent necessary for educational, assessment, credentialing, and quality improvement purposes described in this form.

Use and disclosure authorized: PHI may include, but is not limited to, demographic information, medical history, clinical summaries, and de-identified case materials created from records for the stated educational purposes. Where identifiable PHI is required for case review, it will be disclosed only to individuals directly involved in instruction or assessment and will be safeguarded in accordance with institutional privacy policies.

I acknowledge that participation in educational activities involves minimal risk, including incidental exposure of clinical scenarios. Benefits include enhanced management competencies, documented training records, and eligibility for performance assessments. I retain the right to withdraw this authorization at any time by submitting a written request; however, withdrawal will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

I understand that training records and any evaluations or competency assessments will be retained by the program for administrative, accreditation, and quality improvement purposes. I further acknowledge that de-identified aggregate data may be used for research or program evaluation without additional authorization.

I acknowledge receipt of the program's privacy and confidentiality policies and understand my rights regarding PHI.

I consent to photography, audio, and video recording for training purposes where I am a subject, understanding recordings may be retained as part of training records.

I authorize use of de-identified case data derived from my records for program evaluation and research.

Participant Certification

By signing below, I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I authorize the release and use of my PHI as described above for educational, assessment, and quality improvement purposes. I understand that falsification of information or failure to disclose medical conditions that materially affect participation may result in removal from the program.

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