Healthcare SMA Document

HEALTHCARE SMA DOCUMENT

Patient Information

Patient Name:   Date of Birth:   Gender:

Emergency Contact

Insurance Information

Medical History

Shared Medical Appointment (SMA) Consent and Authorization

Purpose: I understand the Shared Medical Appointment (SMA) is a group-format clinical encounter in which multiple patients are seen together for education, assessment, and coordinated care. My primary reason for attending this SMA is:

Consent to Participate: By checking below I voluntarily consent to participate in the SMA. I acknowledge that the SMA involves group discussion of health information and interaction with other patients and clinical staff.

I consent to participate in the Shared Medical Appointment and to group-based care and education.

Confidentiality and Limits: The clinic and providers will make reasonable efforts to preserve the confidentiality of my medical information disclosed during the SMA. However, confidentiality cannot be absolutely guaranteed in a group setting. I understand the following exceptions permit disclosure of information without my further authorization: 1) suspected child, elder, or dependent adult abuse or neglect; 2) threats of harm to self or others; 3) disclosures required by court order or other legal process; and 4) as required by public health reporting laws. I agree that if I disclose personally identifying information about other participants outside the SMA, such disclosure may breach confidentiality obligations and may subject me to removal from the SMA.

Authorization to Share Clinical Information: I authorize the providers facilitating this SMA to share my relevant medical history, treatment plan, and limited clinical data with other SMA participants and with the multidisciplinary clinical team for the purposes of coordinated care. This authorization does not authorize release of psychotherapy notes or unrelated sensitive information, unless separately specified below.

I consent to audio/video recording of the SMA session for clinical documentation and team review only. Recordings will be stored in secure clinical records and will not be used for public distribution.

Risks and Benefits: Potential benefits include improved access to care, peer support, and more comprehensive education. Risks include inadvertent disclosure of personal health information and reduced privacy compared to individual visits. I have had the opportunity to ask questions about risks and benefits and my questions have been answered to my satisfaction.

Voluntary Nature and Right to Withdraw: Participation is voluntary. I may refuse to participate in or may withdraw from the SMA at any time without penalty and without jeopardizing my access to other clinic services. To withdraw this authorization for future sharing, I must provide written notice to the clinic. Withdrawal will not affect disclosures made prior to receipt of written withdrawal.

If no date is provided, this authorization will expire one year from the date signed.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered or received the clinic's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand that information discussed in the SMA may be included in my medical record and accessed by the care team in accordance with applicable privacy rules.

I acknowledge receipt of the Privacy Practices and consent to uses and disclosures described above.

Patient Certification and Agreement

By signing below I certify that the information provided on this form is accurate to the best of my knowledge. I understand that providing false or misleading information may affect my care. I authorize clinicians to document and use information as described in this SMA authorization and release the clinic from liability for disclosures made in good faith consistent with this authorization and applicable law.

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