SUPPORT GROUP
PRIVACY AND CONFIDENTIALITY STATEMENT AND WAIVER

Privacy and confidentiality are important to everyone who participates in a support group, whether the group is facilitated in person or via a virtual platform. Because support group sessions can involve participants disclosing private medical or social information, all participants in a support group session(s), including the participant and any accompanying caregiver or family member, must agree to respect the privacy and confidentiality of all participants. By signing this Privacy and Confidentiality Statement and Waiver, you agree to respect and protect the privacy and confidentiality of the other participants in the support group session(s) by not revealing medical or any other identifying information after the session is over, and to also make every effort to comply with the terms outlined below.

Additionally, by participating in the support group, you recognize that Ascension St. Mary’s Hospital cannot guarantee that all information will be kept private by other participants in the support group. By signing this Privacy and Confidentiality Statement and Waiver, you acknowledge and agree that Ascension Michigan, and its affiliates, including Ascension St. Mary’s Hospital, shall not be considered liable for any financial or other damages resulting from any breach of confidentiality committed by other participants in the support group sessions, and you fully release the parties from any liability or claims that may arise from such disclosure.

Moreover, because of the risks associated with using technology, we have a decreased ability to fully guarantee confidentiality of your information. To do our best, we are utilizing secure virtual platforms, will engage in virtual support group session(s) over a secure internet connection, and ensure our computers have anti-virus protection. We encourage you to take the same precautions to protect your information.

You also agree to the following to protect the confidentiality of the other participants in the group:
To access the support group session(s) via a secure (non-public) internet connection in a private, closed room where no other people are present and no other people can overhear the group discussions or see your screen;
-Not to record group discussions;
-Not to use last names of group members or disclose any information that could be used to easily identify group members;
Your support group session may be terminated at any time, and will be terminated if it appears there is a confidentiality issue;
All other support group participants must consent to your participation, and consent may be revoked at any time, which could result in the termination of the support group session without notice; and
If technical issues prevent effective participation, the support group session(s) may be ended, and support group discussions will not be interrupted to address technical issues.