Patient Registration Agreement, Release of Liability, and HIPAA Release Form

SCMA Patient Registration Agreement Form
Dear First Name* Last Name*

Thank you for registering with Sickle Cell Medical Advocacy, Inc. (SCMA) and for trusting us to be part of your healthcare journey. SCMA is a nonprofit organization that aims to improve healthcare for patients with Sickle Cell Disease in the USA. We partner with you and your healthcare team during your hospitalization. We know that being in a Sickle Cell crisis can be difficult, and we are here to help you get the best care possible. Before we move forward, however, we must make you aware of our operating guidelines.
1. You are in charge! We are here to help guide you in making optimal health choices for yourself. We will advocate for you as best we can during your hospitalization. We also provide the "Empowered Patient Training" course to teach you self-advocacy. Ask your navigator when the next class starts!
2. We will suggest a better treatment option where we see fit, but we can only suggest one, as we do not have privileges at any hospital. Therefore, please work together with your healthcare team.
3. Please refrain from getting into any verbal or physical altercation with your healthcare staff. Call us so that we can diffuse the situation and get you what you need. Profanity against any hospital staff is strictly prohibited and may result in our inability to represent you. Verbal abuse of any SCMA staff member will result in our inability to represent you.
4. An available healthcare navigator will be assigned to you to help you during an emergency visit or hospitalization. If you are meeting via Zoom for your new-patient interview, please have your camera on. This is a legal requirement. Also, you must be in stable health and able to concentrate for 45minutes to proceed with a patient interview.
5. Signing up with SCMA in advance is ideal. AS SOON AS you think you may need to go to the hospital, check in with us. EARLY intervention is always best!
6. In addition to opiates, your providers will be reminded of other relevant classes of medications suggested by the American Society of Hematology (ASH) for complete sickle cell pain management. Patients must agree to try these treatments based on our expertise. This shows your desire for pain management and not just the use of narcotics.
7. Please complete a SHORT hospital report at the end of each hospital stay. It is now MANDATORY, and ensures we can continue to advocate for you.
8. Sickle Cell Medical Advocacy Inc. reserves the right to end the partnership with any patient if there is reported verbal abuse of SCMA staff, misuse of the alliance, or any misrepresentation of the organization.
Thank you for your adherence to these guidelines. We look forward to advocating for you!

-Sickle Cell Medical Advocacy Inc.
Patient’s Name:

First NameLast Name
DOB:

MonthDayYear
Date Today:

MonthDayYear

Hour MinutesAM/PM Option
Phone Number:
Format: (000) 000-0000.
Email Address:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Signature
What is your hemoglobin genotype?
Are you currently in the ER or admitted to a hospital and in need of a navigator (advocate)?
https://tidycal.com/3ez55l3/medical-advocacy-new-client-appointment
Date Signed:

MonthDayYear
Date
Hour MinutesAM/PM Option

SCMA Release of Liability Form

Don’t blame us for trying to help!
Sickle Cell Medical Advocacy’s providers and sickle cell healthcare navigators are attempting to bridge a gap in your healthcare by helping you get better medical treatment through medical advocacy during your hospitalization.

Our navigators dedicate a large portion of their time to learning the NIH/ASH Sickle Cell Disease guidelines and other important information to help you in this effort.

We do not ask a fee of any patient for this ongoing and important work.

We are not responsible for any complications to your health that you may incur during your hospitalization or emergency room services and cannot be pursued legally at any time for any damages or financial compensation in relation to your care.

Lastly, we reserve the right to end your membership without legal consequence to SCMA if you should pursue any healthcare navigator for financial or other material resources. Navigators donate valuable time to help us. We ask that this be the only resource asked of them.

Thank you for your cooperation, and welcome again to Sickle Cell Medical Advocacy! We look forward to advocating with and for you!
Name

First NameLast Name
Signature

SCMA - HIPAA Release Form

Permission to be part of your healthcare team
Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Section I
I, First Name*   Last Name*   , give my permission for SCMA HEALTHCARE PROVIDER to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.

Section II – Health Information
I would like to permit SCMA HEALTHCARE PROVIDER to: (Tick as appropriate:)

Disclose my complete health record except for the following information: *
Mental health records
Communicable diseases including, but not limited to, HIV and AIDS   Genetic information*

Form of Disclosure:
Electronic copy or access via a web-based portal
Hard copy

Section III – Reason for Disclosure
Please detail the reasons why information is being shared with SCMA HEALTHCARE PROVIDER. If you initiated the request for sharing information and do not wish to list the reasons for sharing, write "at my request".   Type a label


Section IV – Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s):
     Type a Name or an Organization

Section V – Duration of Authorization
This authorization to share my health information is valid: (Tick as appropriate)
a) From    Date  to   Date   or;
b) All past, present, and future periods or;*
c) The date of the signature in section VI until the following event:
Please specify what event

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Organization: SICKLE CELL MEDICAL ADVOCACY INC. (SCMA HEALTHCARE PROVIDER)
Address: 1317 Edgewater Dr., Suite 5035, Orlando, FL 32825

I understand that:
- If my information has already been shared before my authorization is revoked, it may be too late to revoke permission to share my health data.
- I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in Section IV.
- I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI – Signature
Name:First Name*   Last Name*
Signature:      Signature*
Date Today:   Date*
Should be Empty:

SCMA Patient Registration Agreement Form

SCMA Release of Liability Form

SCMA - HIPAA Release Form