INFORMED CONSENT DOCUMENT AGREEMENT TO BE IN A RESEARCH STUDY

Challenge/Study Title	Section – 1
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

Hello there! We’re inviting you to participate in a research study on Efforia. This study focuses on the challenge topic. The information provided here will help you decide if participating in this study is right for you. If you have any uncertainties or unanswered queries, don’t proceed just yet!

The Purpose of This Study

The aim of this study is to understand, analyze and improve the aspects of the challenge topic. We believe your input will provide valuable insights that could lead to remarkable breakthroughs. Your participation will help us create a more inclusive and effective challenge environment.

Your Responsibilities as a Participant

We’re looking for participants who are ready to engage actively and share their experiences. Your role will involve completing certain tasks, providing feedback, and sharing your thoughts. A commitment to honesty, openness, and regular participation is crucial for the success of this study.

Your Rights as a Participant

Remember, your participation is voluntary. You can choose to opt-out at any time. If you decide to drop out, refunds will not be provided. Your rights and privacy will be respected throughout the study.

How to Leave the Study

To exit the study, navigate to your profile page, click on “Your Challenges” and select “leave”. Please note that your join fee is not refundable. This policy helps maintain the integrity of the study for all participants.

Risks and Benefits

Participation in this study may involve some risks. These include the discomfort that may arise from answering difficult questions. On the upside, your participation will contribute to valuable research and you will receive detailed assessments and test results. If you feel distressed during this study, please contact a mental health professional or the National Suicide Prevention Hotline at 988. Before joining, consult with a medical professional if you’re unsure. Remember, some insurance plans may not cover research-related injuries. This study does not provide medical diagnosis or treatment. It’s possible that you may not directly benefit from your participation.

What to do if you have an adverse event or medical emergency

In case of a medical emergency, immediately seek help from your local healthcare provider. Once you’re safe, you can report any adverse events to us at help@efforia.com.

Data Protections

In this study, we’ll collect data related to your challenge experience. Your data is accessible only to those you approve. We’ll use your data to send reminders, personalized reports, and overall findings. All data is stored securely. As this is a community study, we encourage you to share your experiences using Efforia’s features, unless you choose to participate privately. To adjust your communication preferences, follow the instructions in your profile settings. Please review the Efforia Terms & Conditions and Privacy Policy.

If you have questions

Got questions? Feel free to engage with the community! For inquiries you’d rather not share broadly, contact us at help@efforia.com.

California Experiential Research Subject’s Bill of Rights

As a participant in our research, you have certain rights. These include the right to be informed about the study, the right to privacy and confidentiality, the right to withdraw without penalty, and the right to receive a copy of your signed consent form.

HIPAA Waiver

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), we assure you that your health information will be protected. Your identifiable health information will only be used for the purpose of this research study and will not be disclosed without your explicit consent.

Authorization and Consent for Diagnostic Testing

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:
1. 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.
2. 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.
3. 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.
4. 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.
5. My health information and results may be shared with CWI employees and agents for the purpose of ordering, processing, and reporting my results.
6. 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.
7. I authorize CWI to contact me via text message to communicate with me regarding my test.

Patient Rights and Privacy Practices
1. 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.
2. 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.

Release
1. 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.
2. 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.

Important Information