Healthcare Transformation Program

HEALTHCARE TRANSFORMATION PROGRAM PARTICIPANT AGREEMENT

Program Overview

The Healthcare Transformation Program is a coordinated care and quality-improvement initiative that includes care coordination, health coaching, analytics, and health information exchange among authorized partners. Participation begins on and is expected to continue through unless earlier withdrawn as set forth below.

Participant Information

Insurance Information

Medical History

Program Participation Consent

By signing this Agreement, I consent to participate in the Healthcare Transformation Program. I understand that program activities may include care coordination, telephonic and electronic outreach, health coaching, data analysis, and sharing of protected health information with authorized program partners for the purpose of improving my care and health outcomes.

I acknowledge the potential benefits of participation, which may include more timely care, improved care coordination, and access to support services. I understand there may be risks including inadvertent disclosure of information and limitations of remote or telephonic services. Participation is voluntary and I may withdraw at any time without affecting my right to treatment or payment for services.

Phone calls or voicemail at primary phone
Text messages to mobile phone
Email communications to provided email address
Postal mail to provided address

Authorization to Use and Disclose Protected Health Information (PHI)

I hereby authorize the use and disclosure of my PHI to the Healthcare Transformation Program and its authorized partners, including care coordinators, analytics teams, and identified payers, for the purposes of care coordination, quality improvement, population health analytics, and program evaluation. This authorization includes the following categories of information:

Clinical records (diagnoses, medications, lab results, problem lists)
Billing and insurance information
Social determinants of health and care management notes
Behavioral health records where permitted by law

Authorized recipients of PHI include care coordinators, program-employed clinicians, contracted analytics vendors, and my health insurer for care management activities. I understand that once PHI is disclosed to entities other than my treating providers, information may be subject to redisclosure in accordance with applicable law.

I understand I may revoke this authorization in writing at any time, except where action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of written revocation.

Confidentiality, Data Security, and Use Limits

Program participants and partner organizations will apply administrative, technical, and physical safeguards to protect PHI in accordance with applicable law. PHI used for analytics will be limited to the minimum necessary to accomplish program objectives and will be retained only for program-required durations.

Participant Responsibilities

As a participant I agree to provide accurate contact and insurance information, to inform program staff of changes in my health status or contact preferences, and to participate in scheduled outreach efforts. I understand the program is not a substitute for emergency medical care.

Liability and Acknowledgment

I acknowledge that the program and its partners do not guarantee specific clinical outcomes. To the fullest extent permitted by law, I release and hold harmless the program, participating providers, and their contractors from liability for actions taken in good faith under this Agreement, except for willful misconduct or gross negligence.

I certify that I have read and understand the information contained in this Participant Agreement, that my questions have been answered to my satisfaction, and that I consent to participate under the terms described.

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