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. (or SCMA) and trusting us to be a part of your healthcare journey. SCMA is a non-profit organization aiming to improve healthcare for patients with Sickle Cell Disease within the USA. We partner with you and your healthcare team during your hospitalization. We know that being in a Sickle Cell crisis can be a difficult time for you, 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 as best we can for you during your hospitalization and provide patient education classes as a prerequisite.
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 determine how to 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. It helps us to help you if we all remain professional.
4. An available Medical Advocate will be assigned to you to help you during an emergency visit or hospitalization. Please connect well with your Medical Advocate. Help them help you.
5. Signing up with SCMA ahead of time is the best scenario. 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 classes of medications suggested by the American Society of Hematology (ASH) for complete pain management. Patients must agree to try these treatments in addition to opiates. This shows you desire pain management and not just narcotics.
7. Please complete a short survey at the end of the hospital stay. It will provide valuable feedback allowing us to improve our advocacy for others with SCD.
8. Sickle Cell Medical Advocacy Inc. reserves the right to end the partnership with any patient if there is a reported misuse of the alliance or misrepresentation of the organization in any way.
Thank you for your adherence to these guidelines. We look forward to advocating for you!

-Sickle Cell Medical Advocacy
Patient’s Name:*

First NameLast Name
DOB:*

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Date Today:*

MonthDayYear

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Phone Number:*
Email Address:*
Emergency Contact:*

SCMA Release of Liability Form
Sickle Cell Medical Advocacy’s doctors and medical advocates are attempting to bridge a gap in your healthcare by helping you get better medical treatment through medical advocacy during your hospitalization. Our Medical Advocates 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 ifyou should pursue any medical advocate for financial or other material resources. Medical advocates donate valuable time to help us. We ask that this be the only resource asked ofthem.

Thank you for your cooperation, and welcome again to Sickle Cell Medical Advocacy! We lookforward to advocating with and for you!
Patient’s Name:*
Signature*

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Address*

Street Address

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Postal / Zip Code
Date Signed:*

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Date
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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*n

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):
Name:     First Name*   Last Name*

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:
Name: First Name   Last Name
Organization: SICKLE CELL MEDICAL ADVOCACY INC. (SCMA HEALTHCARE PROVIDER)
Address: 1317 Edgewater Dr., Suite 5035, Orlando, FL 32825

I understand that:
- In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel 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*

SCMA - HIPAA Release Form

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.
Should be Empty:

SCMA Patient Registration Agreement Form

SCMA Release of Liability Form

SCMA - HIPAA Release Form