YMCA’S DIABETES PREVENTION PROGRAM CONSENT AND RELEASE FROM LIABILITY
I hereby consent to voluntarily participate in the YMCA’s Diabetes Prevention Program. I understand that the goal of the program is to help adults at high risk of developing type 2 diabetes adopt and maintain healthy lifestyles by eating healthier, increasing physical activity, and losing a modest amount of weight to reduce their chances of developing the disease. I understand that the YMCA does not practice medicine and the program is not a substitute for the care I receive from my physician or other qualified health care providers. I understand that the YMCA’s Diabetes Prevention Program Lifestyle Coach is not a qualified health care professional, does not practice medicine, and support provided by the Lifestyle Coach 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 exercise, 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 YMCA’s Diabetes Prevention Program. By signing below, I affirm that I have read the above in its entirety and I understand the nature of the YMCA’s Diabetes Prevention Program. I also affirm that my questions regarding the program have been answered to my satisfaction. December 11, 2024 AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION I authorize the YMCA of Metropolitan Washington (YMCA) located at 1325 W Street NW, Suite A, Washington DC 20009 to collect and use data in connection with my participation in the YMCA’s Diabetes Prevention 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.
Data/Information to be disclosed: - Health information collected in connection with the YMCA’s Diabetes Prevention Program
The purposes of the disclosure include: - Program administration, operation, and evaluation
- When applicable, to fulfill applicable grant reporting requirements; this may require the re-disclosure of de-identifiable and/or aggregate health information to a third-party, including government entities (e.g., the 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 that the YMCA will not condition my participation in the YMCA’s Diabetes Prevention Program on my providing this authorization
- I understand that 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 share it with others without my permission, if allowed by applicable law. Except as explicitly 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 your completion of your last program, unless a shorter period is specified under state law.
December 11, 2024
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