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 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?

When you volunteer to be part of the Buddy Program you will be matched with another patient with scleroderma, vasculitis, or myositis. By signing this consent, you agree that your name and telephone number may be given to another patient with scleroderma, vasculitis, or myositis who has similarly agreed to be part of the Buddy and who is seeking a Buddy for emotional support through his or her journey with scleroderma, vasculitis, or myositis, Supported Participant. You agree with that you will receive the name and telephone number of the Supported Participant to facilitate communication for the Buddy Program.

You may request to be matched with more than one participant in the Buddy Program. You understand that it is up to the medical team at the SVM as to the number of supported participants you may be matched with.

Importantly, you understand that you should not attempt to give medical advice to your Buddy but rather refer him or her to her doctor for answers to medical questions related to their disease, diagnosis, treatment or care plan.

You understand that if you inform the SVM center/HSS that you or someone else is at risk of harm, this may have to be reported to the relevant authorities - This will be discussed with you first but may be required to report with or without your 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 71st 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.

If HSS has already communicated your name and telephone information to another participant in the Buddy Program before your revocation, we will attempt to recall such information and to let that person know not to contact you.

By signing this consent, you authorize HSS to disclose your name and telephone number to another patient who is participating 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.