SMA Consent Form

Shared Medical Appointment (SMA) Consent Form for California Patients

Kunj Govind Patel MD PC DBA Crissp Clinic
Shared Medical Appointments (SMA) are Group visits! Each patient’s participation is strictly voluntary.

During a typical SMA, 5 to 15 patients are seen together in a setting that encourages asking questions, and sharing concerns and experiences. Patients learn from the healthcare team and from each other in this environment.

Most patients have been overwhelmingly satisfied with the program. They enjoy the opportunity to relate to other people who are dealing with similar health issues, share stories and ideas, learn from one another and truly create a bond. SMAs are particularly valuable to people dealing with chronic conditions like atrial fibrillation, arrhythmias, heart disease, arthritis, chronic pain, and obesity. Every patient has the opportunity to be a role model to someone else!

If they have individual questions that were not addressed during the SMA due to confidentiality or time constraints, they are encouraged to schedule a follow-up appointment to discuss those concerns in detail.

Please note that visits may be recorded for quality assurance purposes; however, these recordings will be permanently deleted shortly after the visit and will not be recoverable.
Confidentiality agreement:

Because group visits involve patients disclosing private medical and social information, all participants in a group visit – including the patient and any accompanying family members/friend – must agree to respect the privacy of ALL participants and keep their information confidential.
By signing this confidentiality agreement, I assume the responsibility for keeping all information confidential.*

Clear
Date*

MonthDayYear
Date
Medical waiver:

Payment for SMA is handled in the same manner as payment for regular/traditional medical appointments. By participating in a group visit, patients assume responsibility for the cost of Deductible, Co-pay, Co-insurance involved, including no-show fee. Note: A Reminder phone call will be made 2 business days in advance. If you wish to change/cancel, same 24-hour notice is appreciated.
By signing this form, I assume the responsibility of paying for my group-visit medical appointment and agree to pay any co-pays and all costs associated with this medical appointment.*

Clear
Date*

MonthDayYear
Date
Are you the patient?

YesNo
If you are signing for the patient, please answer the following:*

I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is First Name* Last Name*, and my relationship to the patient is * .
Patient's Name*

First NameLast Name
Patient's Date of Birth (MM-DD-YYYY):

MonthDayYear
Date
Should be Empty:

Shared Medical Appointment (SMA) Consent Form for California Patients

Confidentiality agreement:

Medical waiver: