CONSENT TO PARTICIPATE IN TELEHEALTH DIABETES PREVENTION PROGRAM
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1.PURPOSE. The purpose of this form is to obtain your consent for a telehealth group session or telehealth individual session with an educator.
2. NATURE OF TELEHEALTH CONSULTATION. Telehealth involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information.
3. RISKS, BENEFITS AND ALTERNATIVES. The benefits of telehealth include having access to education without having to travel outside of your local health care community. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit.
4. MEDICAL INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telehealth. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your consent.
5. CONFIDENTIALITY. All existing confidentiality protections under federal and California law apply to information used or disclosed during your telehealth consultation.
6. RIGHTS. You may withhold or withdraw your consent to a telehealth consultation at any time before and/or during the consult without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
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I hereby agree to be a participant in the DCP Health’s Diabetes Prevention program (DPP). I represent that my participation in DCP’s DPP is voluntary. I acknowledge that I have met the program eligibility requirements prior to starting DCP’s DPP. I acknowledge that DCP’s DPP is educational and informational only and assumes no responsibility for the correct or incorrect use of the information. Any information provided and any recommendations made should not be used to, nor are they intended to, diagnose, treat, cure, or prevent any existing or future disease and/or medical condition. No attempt should be made to use any information provided as a form of treatment for any specific condition or disease without the approval and guidance of a licensed health physician.
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In consideration of my participation in DCP’s DPP for myself, my heirs, and assigns, I hereby release DCP’s employees, partners, agents and management from any claims, recommendations, and causes of action arising from my participation in DCP’s DPP. I agree that if a legal dispute arises concerning my participation in DCP’s DPP or other programs offered by DCP Health, I will attempt to settle the dispute through mediation, and if mediation is not successful, will submit the dispute to binding arbitration conducted in Cook County, Illinois through the American Arbitration Association. I further agree that the laws of Illinois shall apply in any such matter.
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As part of your participation in DCP’s DPP, a program for people with pre-diabetes, we may ask that you complete the requested paperwork, surveys, and functional assessments. All responses/outcomes are kept confidential; your responses/performance will not be shared with anyone outside the DCP’s DPP program. The information you provide may be combined with other respondent’s answers and analyzed and reported in order to help evaluate the program effectiveness, as well as plan future programs.
Thank you for your participation in the DCP’s DPP program.
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