Healthcare Pilot Program

HEALTHCARE PILOT PROGRAM PARTICIPANT AGREEMENT

Program Overview

This Healthcare Pilot Program (the "Program") is a limited-duration clinical or service delivery initiative designed to evaluate specified interventions, technologies, workflows, or care models. Participation is voluntary. The Program may involve collection and use of protected health information and other participant data for the purposes of evaluation, quality improvement, and regulatory reporting as described below.

Participant Information

Insurance Information

Medical History & Current Status

Program Participation & Logistics

Program Site or Setting:

Anticipated Program Start Date:    Anticipated End Date:

Program Components (check each that apply):
Remote monitoring devices and sensors
Mobile application for symptom reporting
Virtual clinician visits
Data sharing for program evaluation

Risks, Benefits, and Alternative Options

I understand that participation may carry risks including, but not limited to, inconvenience, loss of confidentiality, device malfunction, inaccurate measurements, or unanticipated effects of interventions. Potential benefits include improved monitoring, expedited care, or improved health outcomes. Alternatives to participation include continuation of standard care without Program components. Participation is voluntary and may be withdrawn at any time without penalty to the participant's access to clinical care.

Data Use, Privacy and HIPAA Authorization

By signing below, I authorize the release, use, and disclosure of my protected health information (PHI) and other Program-collected data to Program personnel, affiliated researchers, and contractors solely for Program operations, evaluation, quality improvement, aggregate analysis, and regulatory reporting. De-identified or aggregated data may be used for publication, reports, or presentations. Reasonable safeguards will be used to protect confidentiality; however absolute confidentiality cannot be guaranteed.

This authorization expires on: . I may revoke this authorization in writing at any time; revocation will not apply to data already used or disclosed in reliance on this authorization prior to receipt of revocation.

I acknowledge that information disclosed pursuant to this authorization may include health information about substance use, mental health, HIV status, or genetic testing where applicable. I understand special protections may apply to such categories and I consent to their disclosure as described above.

I understand that the Program team may contact me by phone, text message, or email for Program-related communications. I consent to the following contact methods:

Phone
Text message
Email

Compensation, Costs, and Liability

Any compensation or reimbursement for participation will be described in the supplemental schedule provided to the participant. Program-related procedures that are standard clinical care may be billed to insurance. The Program and affiliated institutions are not responsible for loss of employment, insurance coverage, or other nonmedical consequences of participation. Participation does not replace a clinical diagnosis or emergency treatment when required.

By signing below I agree to hold harmless and release the Program and its agents from liability for harm arising from ordinary negligence in Program procedures, except where prohibited by law.

Voluntary Participation and Withdrawal

Participation is voluntary. I may withdraw from the Program at any time by notifying the Program Coordinator in writing. Withdrawal will not affect my right to receive standard care. If I withdraw, I understand that existing data collected up to the point of withdrawal may still be used for Program analysis unless I have revoked my authorization as described above.

Acknowledgments and Consents

I acknowledge that I have read and understand the information in this Agreement, have had an opportunity to ask questions, and agree to participate in the Program under the terms stated herein.

I have read and understand this Participant Agreement and consent to participate.

I authorize use and disclosure of my PHI and data for Program purposes as described above.

Program Contact

Participant Questions / Concerns

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