Consent Form and Permission To Use and Share Your Health Information
Accompany Health Engagement User Research 2023
We are a health care provider that will be opening soon. We are asking you to participate in a project that will help us with our planning.
You do not have to participate.
If you say yes, you can quit at any time.
Please take as much time as you need to make your choice.
We will not provide you with any medical care as part of your participation.
Your medical care and benefits will not change in any way if you say no.
Why sign this document?
To participate and authorize Accompany Health to use your health information for this study, sign this document.
What are we trying to figure out?
We want to learn more about how to help people who have Medicare and Medicaid insurance. This will help us learn more about how we can best engage with our future patients and potential barriers. We are asking people like you who have Medicare and Medicaid insurance to help us.
What happens if I say yes, I want to participate?
If you say yes, we will:
Give you a survey with questions for you to answer.
Potentially schedule an interview to ask you questions.
Ask about your age; household income; household size; health insurance; medical problems; challenges with food; housing, or transportation; contact information and preferences; how you respond to different messages; what barriers you’ve experienced within the health system; etc.
There are no right or wrong answers to these questions. You can skip any question you do not want to answer.
How long will this take?
The Initial Survey, which qualifies you to take part in the Full Survey or Interview, will take approximately 5-10 minutes to complete.
If you qualify for, and desire to participate in, the Interview, it will take approximately 60 minutes to complete.
What information will you use and share?
If you say yes, we will also:
Use and share information regarding your age; household income; household size; health insurance; medical problems; challenges with food; housing, or transportation; contact information and preferences; how you respond to different messages; what barriers you’ve experienced within the health system
How will you use and share my information?
We will use your information only as described in this document.
We may share your name and information with other people at Accompany Health doing planning and analysis so they can contact you about participating in other projects.
We may also share the results of the study with others (like existing or potential customers or partners of Accompany Health) but will not include information that would allow them to identify you personally.
We may also use the results to develop or improve our products.
What happens if I say no?
We will not use or share your information.
No one will treat you differently. You will not be penalized.
The care you get from your doctor will not change.
You will not lose any benefits.
What happens if I say yes, but change my mind later?
You can stop participating at any time. You will not be penalized. You will not lose any benefits.
You may change your mind and revoke (take back) the permission to use your information at any time. Even if you revoke your permission, we may still use or disclose the information already obtained about you as necessary to maintain the integrity or reliability of our analysis, or as required by law.
If you wish to revoke your permission, you have to tell us in writing. Write or e-mail Crosbie Marine at crosbie.marine@accompany.health. If you have any questions, contact Crosbie Marine at crosbie.marine@accompany.health.
Who will see my answers?
The only people allowed to see your answers will be the people who are working on this project.
Your survey answers, health information, and a copy of this document will be locked in our files.
We are not your medical provider and will not put your answers into your medical record.
When we share the results of the study with other Accompany Health employees , we will not include your name. We will take reasonable steps to ensure that no one outside Accompany Health will know that you participated.
Will it cost me anything to participate?
No.
Will participating help me in any way?
It will not help you, but may help people with Medicare and Medicaid insurance in the future.
Will I be paid for my time?
You will not be paid for the Initial Survey, as we use it to qualify people into the paid Interview.
If you qualify for the paid Interview (~60 minutes), we will give you a $50 Meijer, Kroger, Walmart, or Amazon gift card after the completion of the Interview. This is to pay you for your time.
You acknowledge and agree that you will not be entitled to any other compensation in connection with your participation, or in connection with Accompany Health’s use of the results of this project in its commercial business.
Is there any way participating could be bad for me?
Yes. There is a chance that:
How long will my health information be used?
We expect this to take until the end of May 2023. We will keep your information stored, so that we can reach out to you regarding other projects for 2 years.
What if I have questions?
If you have any questions, email Crosbie Marine at crosbie.marine@accompany.health.
Do I have to sign this document?
No. You only sign this document if you want to participate.
What should I do if I want to participate?
You sign this document. We will send you a copy via email.
By signing the document you are saying:
You agree to participate in this project.
You are authorizing us to use and share your health information as described above.
You are also giving permission to contact you about being in other projects.
You know that:
You can email crosbie.marine@accompany.health if you have any questions.
