What You Need to Know to Participate
This document provides information to help you decide whether to join this research study. It is important you understand the responsibilities, risks and benefits of participating.
| INFORMED CONSENT DOCUMENT AGREEMENT TO BE IN A RESEARCH STUDY | |
|---|---|
| Challenge/Study Title | Specific Day Test |
| Challenge Coach (The Person in Charge of This Research Study) | Efforia Advanced Author |
| Sponsor | This study is made possible by your payment to join. |
| Challenge Cost | $0 |
| Included Products & Services | |
| Outcome Measures | |
| Contact | help@efforia.com |
The Purpose of This Study
This study aims to explore the impact of specific day tests on various aspects of human life. We are looking to understand how different factors can influence the outcomes of these tests. The results will help us develop better strategies for future research and studies. With your participation, we can make significant strides in this domain.Your Responsibilities as a Participant
Participation in this study is open to anyone interested in the topic. As a participant, you will be required to complete various tasks and share your experiences. Regular feedback will also be needed to assess the effectiveness of the study. Please ensure you are committed to the study before joining.Your Rights as a Participant
Participation in this study is completely voluntary. You have the right to withdraw from the study at any time without any repercussions. However, please note that refunds for the join fee are not available. Your autonomy and decision-making will be respected throughout the study.How to Leave the Study
To leave the study, go to your Profile page, click “Your Challenges” and click “leave.” Please remember your join fee is not refundable. This payment is important to keep the study experience sound for other participants.Risks and Benefits
Participating in this study may involve some risks such as discomfort from answering personal questions. However, the benefits include access to assessments and test results that may provide insights into your behaviors, patterns, and habits. If at any point you feel overwhelmed, please reach out to a mental health professional. If you ever feel suicidal, contact the National Suicide Prevention Hotline at 988. Remember, your health and safety are paramount.What to do if you have an adverse event or medical emergency
If you experience any medical emergencies or adverse events during the study, seek immediate medical attention. Once you've received appropriate care, please report the incident to help@efforia.com.Data Protections
The data collected in this study includes your responses to specific tasks and your feedback on the study process. This data will be used to improve the study and provide personalized outcome reports. All your data will be stored on secure servers and will only be accessed by individuals you have approved. Review the Efforia Terms & Conditions and Privacy Policy for more details.If you have questions
If you have any questions, feel free to engage with the community or reach out directly to help@efforia.com.California Experiential Research Subject’s Bill of Rights
As a participant in this study, you have the right to be informed about the nature and purpose of the research, your rights, risks, and benefits of participating, and your privacy. You also have the right to withdraw from the study at any point without any repercussions.HIPAA Waiver
By participating in this study, you understand that your health information may be used or disclosed for the research purposes. This waiver does not revoke your rights to healthcare privacy and protections under the Health Insurance Portability and Accountability Act (HIPAA).- Authorization and Consent for Diagnostic Testing
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I voluntarily consent and authorize CWI Physician Partners P.C., a California professional corporation; CWI Physician Partners P.C., a Hawaii professional corporation; CWI Physician Partners P.C., a Georgia professional corporation; CWI Physician Partners P.C., a Kansas professional corporation; CWI Physician Partners P.C., an Oregon professional corporation; CWI Physician Partners P.C., a Nevada professional corporation, CWI Physician Partners P.C., a Rhode Island professional corporation; CWI Physician Partners P.C., an Oklahoma professional corporation, as applicable ("CWI") to review the collection, testing, and analysis for the purposes of a diagnostic screening test. I understand that there are risks and benefits associated with undergoing a diagnostic screening testing and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge the following:
- I am the individual who will provide the sample for the Test(s) that I am requesting or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I am at least eighteen (18) years of age or I am the parent or legal guardian of a minor who is providing the sample for testing.
- I have read and understand the information provided about the Test(s) that I have been provided on the website where I requested the Test.
- The information I have provided in connection with my request to CWI is correct to the best of my knowledge. I will not hold CWI or its employees or agents responsible for any errors or omissions that I may have made in providing such information.
- My health information and results may be shared with CWI employees and agents for the purpose of ordering, processing, and reporting my results.
- Medical Services provided by CWI are purely for diagnostic assistance purposes and do not create a physician-patient relationship, and do not constitute medical care or diagnosis or treatment of any condition, disease, or illness.
- I authorize CWI to contact me via text message to communicate with me regarding my test.
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Patient Rights and Privacy Practices
- Notice of Privacy Practices and Patient Rights: CWI Notice of Privacy Practices describes how it may use and disclose your protected health information for other purposes that are permitted or required by law. To review a copy of CWI Notice of Privacy Practices, go to http://www.CynergyWellness.com.
- Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be disclosed to appropriate county, state, federal, or other governmental and regulatory entities as may be permitted by law.
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Release
- To the fullest extent permitted by law, I hereby release, discharge and hold harmless, CWI, including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my diagnostic test or the disclosure of my test results.
- By selecting the ACKNOWLEDGEMENT during the registration process for diagnostic testing, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have read the contents of this form in its entirety and voluntarily consent to proceed with these procedures.