Enrollment Form

Patient Questionnaire & Consent

Patient Information

First Name

Last Name

Phone

Home Address

City

State

Zip Code

Age

Date of Birth

Caregiver/Emergency Contact Information

First Name

Last Name

Phone

Patient Demographic Data

Race

American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Black or African American White Other race Unknown Prefer not to answer

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Prefer not to answer

Gender you most identify with

Female Male Other gender identity Prefer not to answer

Medical History

Type of advanced medical treatment or procedure

Date of procedure

Does the patient have any allergies to medications?

Household Income

Information on your household income allows us to see if you qualify for additional resources that include support for housing, meals, transportation, and/or parking. To see if you are eligible, you must fill out the income or insurance information below.

Note: ALL participants, regardless of income, are offered health navigation services, pill box management, vital sign record logs, social work support, translation services, and a touch point meeting post discharge.

Please identify which of the below most accurately represents your household income?

$0 - $25,000 annually $25,001 - $50,000 annually $50,001 - $75,000 annually $75,001 - $100,000 annually $100,001 - $125,000 annually $125,001 - $150,000 annually Over $150,000 annually Prefer not to answer

What is the size of your household?

1 person 2 people 3 people 4 people 5 or more people Prefer not to answer

What insurance coverage do you have?

Medicare Medi-Cal Private insurance Other (please describe below) Prefer not to answer

Your insurance (if you replied "Other" above)

Interested in connecting with a peer mentor?

We have a network of previous transplant and LVAD recipients, as well as caregivers, who have volunteered to help guide and support individuals facing advanced medical therapies for organ failure. They are available to share their experiences, answer questions, and offer non-medical advice about the process and life after advanced medical therapies.

If you are interested in being contacted by a transplant mentor, please check the box below to authorize your name and contact information to be shared with them.

I consent to have my basic information (name, phone number and/or email) shared with a transplant mentor and consent to them contacting me I am not interested

If you consented to be contacted above, please indicate your preferred method of contact:

Phone Email WhatsApp Other (provide details below)

Provide preferred contact details here:

Consent For Participation in Health Navigator Foundation Program

I hereby voluntarily consent to participate in the Health Navigator Foundation Program (the “Program”) and to retain the services of the Health Navigator Foundation and its Medical Director and its staff to assist, guide, counsel and advise me as set forth below.

Privacy Policy

By checking this box, I hereby acknowledge that I received information from Health Navigator Foundation regarding its Privacy Practices. I further understand that I may contact the Health Navigator Foundation if I have any questions regarding the contents of this Notice of Privacy Practices. For more information, view our Privacy Policy.*

As an organization, we are constantly striving to improve the quality of service that we provide to individuals after advanced organ failure therapies. As part of this process, we conduct comprehensive surveys and an exit interview with each program participant. The information obtained via survey and audio and/or video interview will be recorded, securely stored, and destroyed once analyzed for the purpose of programmatic improvement. The results of this data will be used to tailor our care to our participants.

By initialing below, I acknowledge that my participation in the Health Navigator Foundation (HNF) includes completion of the requested surveys and exit interview which will be audio/video recorded by HNF staff, as part of ongoing programmatic improvement efforts for the HNF.

Your initials

Video/Audio Recording Consent

The undersigned patient consents to the Health Navigator Foundation collecting a video/audio recording of the voluntary qualitative interview. All recorded content will be maintained securely by the HNF and will be destroyed upon completion of analysis for quality improvement. The undersigned:

Consents to audio/video recordings of interviews with the Health Navigator Foundation, which will be used for purposes of programmatic quality improvement.
Waives any right to compensation for use of the audio/video recordings.
Holds the Health Navigator Foundation harmless from and against any claim of injury or compensation resulting from the activities authorized by this Consent.

What is the Health Navigator Foundation Program

The Program is a service that assists, guides, counsels and advises patients through the transplant or Left Ventricular Assist Device implantation.

This consent is your consent to participate in this Program. You understand that we will be providing no medical treatment or medical services to you as part of this Program. We are here to guide and navigate you through the transplant process. The Program is here to provide advice and interpretation through the complex advanced organ failure therapy process, but will not be acting as your doctor or provide medical treatment to you as part of this Program.

I acknowledge that no guarantees have been made to me as to the effect of recommendations and/or guidance provided by the Program and/or its associates. I hereby disclaim, indemnify, release and hold harmless the Health Navigator Foundation and its staff from any claims, actions, and/or damages I may have, now or in the future, in connection with their services hereunder and the Program.

What the Health Navigator Foundation Program is NOT

As stated above, the Program does not provide any medical treatment or medical services to patients.

Study and Research Goals of the Program

In addition to providing guidance and counseling to patients, the Program seeks to study and analyze the following data in connection with advanced organ failure patients:

Total length of stay in the hospital (including pre-operative and post-operative stay).
Rate of hospital readmission.
Complication rates.
Survival rates.
Other data and results in connection with the above.

Authorization To Use Health Data For Research Purposes

Because information about you and your health is personal and private, it generally cannot be used in this Program without your written authorization. If you sign this form, it will provide that authorization.

What kinds of data will be collected, and by whom?

Data collection, treatment and study will be supervised by a physician and Medical Director. The focus will be on quality outcomes including survival/complication rates, readmission complications like infection or rejection, and length of hospital stay. Specific data gathered may include some or all of your medical records, information about the medicines you take, the results of blood tests or other lab work, and other health information.

Do I have to sign this authorization form?

You do not have to sign this authorization form. But if you do not, you will not be able to participate in this Program. Signing the form is not a condition for receiving any medical care outside the Program.

If you decide to participate, you are free to withdraw your authorization regarding the use and disclosure of your health information (and to discontinue any other participation in the study) at any time. After any revocation, your health information will no longer be used or disclosed in the Program and any of its studies, except to the extent that the law allows us to continue using your information (e.g., necessary to maintain integrity of research). If you wish to revoke your authorization for the research use or disclosure of your health information in this study, you must write to: Health Navigator Foundation, c/o Health Resource Center, 2100 Webster Street #100, San Francisco, CA 94115

Signature

Patient's Signature (type your full name)

Date