Consent Form for Online Diabetes Education Classes

 Starling Physicians Informed Consent for Virtual Group Meetings 

Purpose: Starling Physicians wishes to provide a neutral setting for patients and community members to attend group meetings to discuss particular conditions or treatment courses. There are many potential benefits to participation, some of which include comfort in knowing that you are not alone, understanding that others have similar concerns and sources of stress, the opportunity to gain perspectives from multiple people, consistency and routine, and motivation to continue in a forward path and reach goals and milestones. 

Technology: 

Starling Physicians is presently using Webex for group meetings. You will not have to purchase a plan to use this program. We reserve the right to change the platform we use at any time based on new information. You will be informed of any changes that occur. 

This system meets HIPAA standards of encryption and privacy protection, but we cannot guarantee privacy. Further, we will conduct the group meeting over a secure internet connection, and ensure that our computers have anti-virus protection. We ask that you take the same precautions to protect your information. 

Potential Risks of Virtual Group Meetings: 

There are risks in utilizing this technology to engage in group meetings, such as unauthorized access to the meeting, resulting in breaches of information, and technical difficulties, which can not be predicted or fully controlled. Starling Physicians can not guarantee your privacy when you are participating in a group meeting. 

At times, people may have difficulty reading non-verbal cues from one another and knowing when to speak in order to avoid interrupting others. Please be patient with others and with the facilitators throughout this process. 

Also, please respect that information about group members should not be discussed outside of the meeting. This includes the use of social media platforms. Starling Physicians reserves the right to dismiss group members who violate this policy. 

Participation: 

Your participation in these group meetings is completely voluntary. If you wish to discontinue attending the meetings, you may do so at any time. There is no obligation on your part to attend the meetings, and any decision you make to participate will have no impact on any medical treatment or plan of care with any provider at Starling Physicians. 

Informed Consent for Participation in Virtual Group Meetings _ July 2020 

Your Responsibilities: 

Out of respect for other meeting attendees, and in an effort to promote a reasonable amount of privacy in this setting, you must follow these important guidelines: 

• Log in at or before the start time to minimize interruptions after the meeting has begun 
• Secure a (non-public) internet connection 
• Do not record (video, audio, or screen shots) any meeting or any portion of any meeting 
• Connect from a quiet and private room to minimize interruptions or distractions 
• Other persons not actively attending the meeting should not be within hearing or visual proximity 
• Remove, turn off, or mute other electronic devices 
• Should someone enter the area while you are in the meeting, cover your screen and mute your microphone or telephone 
• Do not disclose names or personal issues/experiences of meeting attendees outside of the group meeting 

Understanding and Consent: 

Starling Physicians is proud to provide this important opportunity to participate in group meetings. 

By completing and signing this consent form, you are confirming: 

1. I have read and fully understand this document. 

2. Any questions I had have been answered to my satisfaction. 

3. I agree to the responsibilities stated above. 

4. I authorize Starling Physicians to send invitations and meeting materials to my designated e-mail account. 

5. I do not hold Starling Physicians accountable for unauthorized access to this meeting or any associated information.