Workshop Consent Forms

NCOA Consent Form

Statement of Consent

Please show us that you understand the information on the Participant Consent Form and how your survey information will be used. Check each box you agree to and sign below. Typing your name and today’s date will act as your digital signature.
I have read the information on this form or it has been read to me. I understand the information and have received answers to any questions I asked. I understand that I do not have to complete the survey and if I do not, it will not affect the services I receive.
I agree to allow my survey information to be shared with ACL and its contractors.
I agree to allow my gender, zip code and date of birth to be shared with CMS or its contractors to match with my Medicare claims information.
Signature of Participant(Required)
MM slash DD slash YYYY
Signature of Guardian/Family Member/Legal Representative
MM slash DD slash YYYY
Clear Signature