Attachment C - MBCCP Consent Form.docx

Massachusetts Breast and Cervical Cancer Program Participant Agreement

The Massachusetts Department of Public Health (MDPH), working with the U.S. Centers for Disease Control and Prevention (CDC) administers a program called the Massachusetts Breast and Cervical Cancer Program (MBCCP). MBCCP offers free health screenings and diagnostic services for people who have no health insurance coverage for these services or who are underinsured and cannot otherwise pay for these services.

I choose to enroll, and:

· I understand what free services will be provided by the MBCCP.

· I have had an opportunity to ask questions about the MBCCP Program.

· I understand that enrollment in the MBCCP is voluntary, and that I may choose not to participate at any time.

· If I choose to stop participating in the MBCCP, I will not have to pay for services I have received while enrolled.

· If requested, I will sign an authorization for release of personal health information (PHI) to the Massachusetts Department of Public Health or to any MBCCP Medical Site Contractor or clinician for my treatment, coordination of care, or payment for MBCCP services.

· I understand that if I am diagnosed with cancer, my health care provider is required by state law to report my name, address, Social Security number (if available), and diagnosis to the Massachusetts Cancer Registry. This information is kept confidential and is used to track cancer incidence in Massachusetts.

· I understand that I may be contacted at least once per year for re-screening, case management and/or follow-up services. This contact may be made by the clinician.

· My eligibility to receive MBCCP services will be reviewed every year.

How MDPH Uses Personal Health Information The Massachusetts Department of Public Health Breast and Cervical Cancer Program (MBCCP) collects personal health information (PHI) from you or about you that allows us to identify you as an enrolled participant for purposes of care and billing. PHI may consist of your name, address, date of birth, dates of tests, test results, treatment dates, type of treatments, health care services you receive and payments that are made for services while you are enrolled in the MBCCP. This information will be used for:

· Billing

· Verification for the accuracy of cancer reporting as authorized by law

· Tracking your medical services for timely delivery

· Monitoring diagnostic evaluations for abnormal test results

· Assurance that you are offered and receive MBCCP services, as appropriate.

Notice of Release of Personal Health Information

I understand that my personal health information related to my participation in the MBCCP will be released from the MBCCP Medical Site(s), where I go for services, to the Massachusetts Department of Public Health and to other contracted medical providers within the MBCCP only as required:

· For payment for MBCCP services that are provided to me;

· For health care operations such as enrollment, care coordination, billing, tracking services, improving the quality of services;

· For treatment to health care providers (doctors, nurses, and other caregivers) who request it in connection with preventive health initiatives, early detection programs, disease management programs and case management activities.

· For reporting to meet federal reporting requirements for funding of the MBCCP program. Any information reported by DPH to the federal CDC will NOT include my name or information that would identify me.

· For evaluating the impact of the program, such as did the program help increase breast and cervical cancer screenings in Massachusetts.

I understand that MDPH is required to follow state and federal privacy laws and may not release personal health information about me without my written permission unless required to do so by law.

Participant Name (Printed)

__________________________________________ Date _____________________________ Participant Signature Month Day Year