The Scleroderma, Vasculitis & Myositis Center ( SVM ) Center Buddy Program through the Hospital for Special Surgery (HSS)

What is the Buddy Program?
The Buddy Program is a patient support network in which patients who have been diagnosed with scleroderma, vasculitis or myositis may volunteer to have connect with and offer emotional support to others who have been diagnosed with scleroderma, vasculitis, or myositis.

What happens if I agree to take part in the Buddy Program as a Supported Participant?

When you agree to be part of the Buddy Program as a supported participant you will be matched with another patient with scleroderma, vasculitis, or myositis. By signing this consent, you agree that you will receive the name and telephone number of the Buddy Program volunteer who is another patient with scleroderma, vasculitis, or myositis who has similarly agreed to be part of the Buddy Program. You also agree that HSS may communicate your name and telephone number to the Buddy Program volunteer with whom you are matched.

Importantly, you understand that the Buddy Program volunteer is not a representative of HSS and you should not receive any medical advice to your Buddy. You should refer all your medical questions related to your diagnosis or treatment to your medical doctor.

I understand that if I inform the SVM center/HSS that myself or someone else is at risk of harm, this may have to be reported to the relevant authorities - This will be discussed with me first but may be required to report with or without my permission.

When will this consent expire?

This consent expires the earlier of: (i) five (5) years from the date it is signed or (ii) when HSS receives a written request from you to withdraw from the Buddy Program. By writing to: Scleroderma, Vasculitis & Myositis (SVM) Center 525 East 71 Street. NY, NY, 10021

Privacy of Your Information Disclosed to Other Buddy Program Participants.

You understand that the other participants in the Buddy Program who receive your information and with whom you communicate as part of the Buddy Program are not required to maintain the confidence of any such information, including any the information you may communicate to them as part of the Buddy Program.

Can I revoke this consent?

You can revoke this consent at any time by notifying the staff at the SVM Center at (212) 774-2048. By signing this consent, you authorize HSS to disclose your name and telephone number to a Buddy Program volunteer with whom you are matched to participate in the Buddy Program, as described above. You understand that you may not benefit directly from participating in the Buddy Program. You have a right to refuse to sign this consent. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not sign this form. You also have a right to receive a copy of this form after you have signed it.