YMCA's Blood Pressure Self-Monitoring

BLOOD PRESSURE SELF-MONITORING PROGRAM

CONSENT AND RELEASE FROM LIABILITY

I hereby consent to voluntarily participate in the Blood Pressure Self-Monitoring Program with South Carolina Alliance of YMCAs, virtually or in-person. I understand the goal of the program is to reduce blood pressure and improve blood pressure management among adults who have been diagnosed with high blood pressure.  

 

I understand the YMCA does not practice medicine and the Blood Pressure Self-Monitoring Program is not a substitute for the care I receive from my physician or other qualified health care providers. I understand the Blood Pressure Self-Monitoring Program Healthy Heart Ambassador (HHA) is not a qualified health care professional, does not practice medicine, and that support provided by the HHA is not a substitute for the care I receive from my physician or other qualified health care providers.

 

In consideration for being allowed to participate in this program, I agree to assume the risk of such activity, and further agree to hold harmless the YMCA, its employees and agents, from any and all claims, suits, losses or related causes of action for damages, including, but not limited to, such claims that may result in my injury or death, accidental or otherwise, during or arising in any way from my participation in the Blood Pressure Self-Monitoring Program.

 

By signing below, I affirm that I have read the above in its entirety and I understand the nature of the Blood Pressure Self-Monitoring Program. I also affirm that my questions regarding the program have been answered to my satisfaction.

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

I authorize the South Carolina Alliance of YMCAs located at 151 S Oakland Avenue, Rock Hill, SC, collect and use data in connection with my participation in the Blood Pressure Self-Monitoring Program, maintain this data in a data capture system, and disclose (i.e., share) this data to the YMCA of the USA (Y-USA) located at 101 N. Wacker Drive, Chicago, IL 60606, and South Carolina DHEC located at 2600 Bull Street, Columbia, SC 29201.  

 

Data/Information to be disclosed:

Health information collected in connection with the Blood Pressure Self-Monitoring Program

The purposes of the disclosure include:

·        Program administration, operation, and evaluation

·        Research activities approved by an Institutional Review Board (IRB)

·        To enter into the YMCA’s data system for the Blood Pressure Self-Monitoring Program for purposes of tracking and verifying health outcomes related to the Blood Pressure Self-Monitoring Program

·        When applicable, to fulfill applicable grant reporting requirements. This may require the re-disclosure of de-identified and/or aggregate health information to a third-party, including government entities (e.g., the U.S. Centers for Disease Control and Prevention)

By signing below:

·        I authorize the use and disclosure of my health information as described above for the purposes indicated.

·        I understand that I have the right to receive a copy of this authorization.

·        I understand the YMCA will not condition my participation in the Blood Pressure Self-Monitoring Program on my providing this authorization.

·        I understand the YMCA may receive payment or compensation (generally in the form of grants) from Y-USA, and, in some cases, such grants may condition funds on the disclosure of health information to Y-USA.

·        I understand that persons or entities that receive health information under this authorization may not be bound by privacy laws (such as the federal law called HIPAA or other state data privacy laws) that protect the health information and, as such, may disclose it to other persons or entities without my permission, if allowed by applicable law. Except as stated in this authorization, Y-USA may not further disclose my health information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.

·        I understand that I may revoke this authorization at any time by submitting my revocation in writing to the YMCA, and the revocation will not affect information that has already been used or disclosed.

·        If this authorization has not been revoked, it will terminate five (5) years after completion of your last program, unless a shorter period is specified under state law.

 

AUTHORIZATION FOR RELEASE OF INFORMATION 

TO HEALTH CARE PROVIDER

I voluntarily authorize SC Alliance of YMCAs to release or disclose my health information related to my participation in the Blood Pressure Self-Monitoring Program to my Primary Care Physician and/or other individuals referenced below. I understand I have a right to receive a copy of this authorization and that the information disclosed pursuant to this authorization may be redisclosed by the person(s) listed below. I understand I am not required to sign this form to participate in the program, and that I may revoke this authorization at any time by submitting my revocation in writing to the YMCA.