Consent Form and Permission To Use and Share Your Protected Health Information

Accompany Health Engagement User Research 2022

We are asking you to be in a research study. You do not have to be in the study. If you say yes, you can quit the study at any time. Please take as much time as you need to make your choice. Your medical care will not change in any way if you say no.

 

Why sign this document?

To be in this study and authorize researchers from Accompany Health to use and share your health information for this study, you will need to sign this document while taking the Initial Survey.

Why are you doing this research study?

We want to learn more about how to help people who have Medicare and Medicaid insurance. This study 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 be in the study?

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 the study 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 Full Survey, it will take approximately 30 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 for the study?

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

The information we are asking to use and share is called “Protected Health Information.” It is protected by a federal law called the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). In general, we cannot use or share your health information for research without your permission.

If you want, we can give you more information about the Privacy Rule. Also, if you have any questions about the Privacy Rule you can speak to our Privacy Officer at privacy@accompany.health.

How will you use and share my information?

• We will use your information only for the study described in this document.
• We may share your name and information with other people at Accompany Health doing research on people with Medicaid and Medicare insurance (“Accompany Health Researchers”) so they can contact you about being in other research studies.
• We may also share the results of the study with others (e.g., existing or potential customers or partners) but will not include information that would allow you to identify you personally. 
• We may also use the results of the study for research and development purposes, including to develop and/or improve our products.
• To the extent your Protected Health Information is shared with people who do not have to follow the Privacy Rule, your information will no longer be protected by the Privacy Rule. 

What happens if I say no?

If you say no:

• We will not use or share your information for this study.
• 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 being in the study at any time. You will not be penalized. You will not lose any benefits.

You may change your mind and revoke (take back) the authorization to use your information at any time. Even if you revoke your authorization, we may still use or disclose the information already obtained about you as necessary to maintain the integrity or reliability of the study, or as required by law. 

 

If you wish to revoke your authorization, you have to tell us in writing. Write or e-mail Kylie Murrin at kylie.murrin@accompany.health. If you have any questions, contact Kylie Murrin at kylie.murrin@accompany.health.

If you do, the care you get from your doctor will not change.

Who will see my answers?

The only people allowed to see your answers will be the people who work on the study and people who make sure we run our study the right way.

Your survey answers, health information, and a copy of this document will be locked in our files. We will not put your answers into your medical record.

When we share the results of the study with other Accompany Health employees (i.e., other than Accompany Health Researchers), we will not include your name. We will take reasonable steps to ensure that no one outside the study will know you are a part of the study.

Will it cost me anything to be in the study?

No.

Will being in this study help me in any way?

Being in the study 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 Full Survey or paid Interview.

If you qualify for the paid Full Survey (~30 minutes), we will give you a $20 Amazon, Walmart, or Target gift card after the completion of the Full Survey. This is to pay you for your time. 

If you qualify for the paid Interview (~60 minutes), we will give you a $50 Amazon, Walmart, or Target 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 in the study, or in connection with Accompany Health’s use of the results of this study in its commercial business.

Is there any way being in this study could be bad for me?

Yes. There is a chance that:

• The questions could make you sad or upset.
• Someone could find out that you were in the study and learn something about you that you did not want others to know.

 

How long will my health information be used?

We expect our study to take until the end of 2022. We will keep your information stored, so that we can reach out to you regarding other research projects for 2 years. 

What if I have questions?

If you have any questions about the study, email Kylie Murrin at kylie.murrin@accompany.health. Please reach out if you have:

• Any questions about the study.
• Questions about your rights.
• Concerns that you have been injured in any way by being in this study.
• Questions about how we will use this information.

Do I have to sign this document?

No. You only sign this document if you want to be in the study.

What should I do if I want to be in the study?

You sign this document. We will send you a copy via email.

By signing the document you are saying:

• You agree to be in the study.

• You are authorizing us to use and share your health information for this study as described above.

• You are also giving permission to contact you about being in other research studies.

You know that:

• You can skip questions you do not want to answer.
• You can stop answering our questions at any time and nothing will happen to you.
• You can email the office in charge of research at kylie.murrin@accompany.health if you have any questions about the study or about your rights.