Agreement:
Institutions performing Mechanical Circulatory Support (MCS) procedures ("Participant") are invited to participate in a cooperative survey (hereinafter the "Survey") involving patient satisfaction with care within their MCS program
Scope:
The Participant shall collect and submit to the Survey patient satisfaction information at every patient encounter using a web based interface. This information will be de-identified and data transmitted and stored by MyLVAD using HIPPA compliant Jotform and Google Enterprise secure servers. The web based Survey requires patient registration and direct patient input to complete the survey on MyLVAD.com.
Participant AGREES THAT THEY ARE responsible for advising patients that their NON-PATIENT IDENTIFIED data will be used in this REGISTRY AS REQUIRED BY THEIR INSTITUTIONAL REVIEW BOARD RECOMMENDATIONS and THAT PARTICIPANT HAS obtained all requisite patient consents PRIOR TO SUBMITTING PATIENT DATA.
Relationship:
It is understood and agreed that the services described herein are to be performed by Participant as an independent contractor, and neither it nor any of its employees will, for any purpose, be considered an employee of MyLVAD. Participant, as an independent contractor, is solely and exclusively liable to third parties for all costs and other liabilities incurred by Participant for all claims or damages arising out of or based upon its performance of this Agreement. MyLVAD shall not assume liability for claims or losses arising from the acts or failures to act of another, except to the extent such claims or losses may be caused by MyLVAD or a third party to whom MyLVAD provided data and analyses as set forth herein. MyLVAD and Participant shall indemnify and hold harmless one another, and the other’s officers, agents, employees and members from any liability, including but not limited to attorneys’ fees and costs, of whatsoever nature or kind arising out of, as a result of, or in connection with the performance of this Participation Agreement, and the use or nonuse of data and analyses, but only to the extent such liability is due to the actions or omissions of its own officers, employees or agents, except to the extent provided herein.
Confidentiality:
MyLVAD shall not disclose any data that would be in violation of any provision contained in any contract between MyLVAD or any of its affiliate entities and any government agency or that would be in violation of the Health Insurance Portability and Accountability Act of 1996 or Privacy Act of 1974, as amended.
By agreeing to the terms of this Participation Agreement, Participant hereby authorizes the release of its data to MyLVAD and authorizes MyLVAD to release such data and analyses to third parties. This authorization is material to Participant’s inclusion in the Survey and if Participant declines to authorize the release of its data to MyLVAD or authorize MyLVAD to release its data to third parties, that Participant’s data will not be included in Registry reporting.
Representations:
Authority:
The undersigned represents that they have full authority to execute this Agreement on behalf of the party for whom they are signing, and acknowledges that MyLVAD is relying on such representation in entering into this Agreement.