ICPA Diplomate PBRN Agreement

ICPA Practiced Based Research Network (PBRN) Agreement

Participation in the ICPA Practice-Based Research Network is voluntary, although practitioners with particular practice characteristics may be invited to participate in order to meet the goals of specific projects. Agreement to participate will in no way be interpreted as creating an agency or employment relationship between the parties or as giving rise to a joint venture or formal business partnership between practitioners and the ICPA, Inc.

Practitioners who agree to participate in this program and who sign the form agree that they will:

  1. Follow all data collection and return protocols as accurately and completely as possible.
  2. Maintain patient confidentiality as appropriate.
  3. Communicate with central office if significant changes occur in their practice (such as moving, liability insurance changes, license status changes, discontinuing practice or participation in the PBRN).
  4. Make their relevant files and log books available for record checks for quality assurance purposes, understanding that these checks are confidential.
  5. Obtain written approval from the I. C.P.A. Executive Coordinator, Dr. Jeanne Ohm, for release of information to the public relating to the program prior to such release, except for the use of approved press releases and letters provided by the ICPA office for this project.
  6. Not use the project or their participation in it in any way, shape or form to recruit patients. Such use is strictly prohibited by the ICPA.
  7. Provide the I.C.P.A with a copy of your current license and malpractice cover sheet policy.

The ICPA Practice-Based Research Network agrees to fulfill the following obligations to participating practitioners:

  1. Protect patient confidentiality, using only case ID numbers.
  2. Protect practitioners’ confidentiality, both in routine data collection and reporting and in quality assurance procedures.
  3. Provide necessary training to staff and practitioners.
  4. Communicate regularly with participants, with a minimum of one annual progress report and any significant changes in the PBRN.
  5. Provide a summary report at the end of each project.
  6. Acknowledge doctor’s participation in all resultant publications, after receiving written permission from each practitioner to be named, and provide participants with a copy of the publication.

Furthermore:

  1. Parties to this agreement will not discriminate on the basis of race, creed, color, sex, national origin, religion, age or disability in this agreement or as to any aspect of it.
  2. Practitioner agrees to identify and hold the ICPA harmless from any loss, claim, damage or liability of any kind except to the extent that it arises from the gross negligence or willful misconduct of the ICPA.
  3. By sharing clinical findings with the ICPA/PBRN the practitioner understands that the ICPA is not involved in their patient management and care.
  4. This agreement will be governed by and construed under the laws of the state of Pennsylvania

This participation agreement is recorded on my date of on-line registration for the ICPA Diplomate PBRN.