INFORMED CONSENT DOCUMENT AGREEMENT TO BE IN A RESEARCH STUDY

Challenge/Study Title
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

Hey there, we’re excited that you’re considering joining a research study here on Efforia. This is a big decision and you should take your time to understand what’s involved. This document has all the information you need to make an informed choice. Don’t continue if you’re unsure or have unanswered questions, we’re here to help: just reach out to us at help@efforia.com.

The Purpose of This Study

Insert here a four sentence summary of the purpose of this study.

Your Responsibilities as a Participant

Insert here a four sentence summary of what kinds of participants are appropriate for this study and what is involved of participants.

Your Rights as a Participant

Remember, participating in this study is 100% voluntary. You can decide to leave whenever you want, no hard feelings. But, just so you know, we can’t refund your join fee. We use those funds to keep the study running smoothly for other participants.

How to Leave the Study

Decided this isn’t for you? No problem. Just go to your Profile page, click on “Your Challenges”, and hit “leave”. Just remember, your join fee is non-refundable. This helps us keep the study fair and enjoyable for all other participants.

Risks and Benefits

Insert here a paragraph outlining the risks and benefits of participating in the study, including specific risks of treatments and any mental health risks. Remember to seek advice from an expert, like a doctor or life couch if you have any doubts. If at any point you feel suicidal, contact the National Suicide Prevention Hotline immediately by dialing 988. Please note that some insurance plans may not cover research-related injuries, so check with your insurer. This study does not provide a medical diagnosis or cure. You may not benefit directly from participating, but you will receive assessments and test results.

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

If you experience an adverse event or medical emergency, get medical help immediately. Once you’re taken care of, let us know by emailing help@efforia.com.

Data Protections

We’ll be collecting data during this study, but don’t worry, your data is safe with us. We only share it with those you’ve given the thumbs up to. You’ll get reminders, personalized reports, and overall findings via email, SMS, and push notifications. Adjust your communication preferences to suit your comfort level. Please review the Efforia Terms & Conditions and Privacy Policy for more info.

If you have questions

Got questions? That’s what the community’s here for! Or, if you’re not comfortable asking publicly, email us at help@efforia.com.

California Experiential Research Subject’s Bill of Rights

Insert here a one paragraph summary of the California Experiential Research Subject’s Bill of Rights.

HIPAA Waiver

Insert here a one paragraph HIPAA waiver.

1. Authorization and Consent for Diagnostic Testing

1. 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.

1. 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.

1. 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.