HIPAA Compliance Form

44th Annual North American Burn Society Conference - 2026

The Health Insurance Portability and Accountability Act (HIPAA) states that patient records and photos used in teaching must be stripped of all “direct identifiers” such as name, address, social security number, patient ID number, identifiable photographic images, etc., or that you have written authorization from the patient to use their directly identifiable health information for this purpose. The REACH Burn Foundation CME Activity Committee requires you, as a presenter participating in a CME activity, to verify by way of your signature below that your presentation materials meet these HIPAA standards. Presentation materials include, but are not limited to, handouts, slides, PowerPoint presentations, videos and reproductions of journal articles. Please feel free to ask the CME Activity Committee if you have any questions or need additional information. Thank you for your participation and cooperation.

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Name

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Phone*

Activity Title*

Activity Date*

Topic*

Content Validation Compliance

I reviewed the policy on content validation and agree to present valid content that is accepted within the profession of medicine as adequate justification for these indications and contraindications in the care of patients.*

Yes

Disclosure is required to inform course participants that an off-label drug use or an investigational device will be discussed. Do you plan to discuss off-label uses of medications or investigational devices during your presentation?*

Yes

N/A

I agree to state in my presentation(s) that I am referencing unapproved drug or devices.*

Yes

N/A

Presenter - HIPAA Compliance

Presenter's Name*

First Last

Activity Title*

Presentation Activity Date

Presentation Title*

From: REACH Burn Foundation Activity Committee
RE: HIPAA Compliance and CME Activity Materials
The Health Insurance Portability and Accountability Act (HIPAA) states that patient records and photos used in teaching must be stripped of all “direct identifiers” such as name, address, social security number, patient ID number, identifiable photographic images, etc., or that you have written authorization from the patient to use their directly identifiable health information for this purpose. The REACHBF CME Activity Committee requires you, as a presenter participating in a CME activity, to verify by way of your signature below that your presentation materials meet these HIPAA standards. Presentation materials include, but are not limited to, handouts, slides, PowerPoint presentations, videos and reproductions of journal articles. Please feel free to ask the CME Activity Committee if you have any questions or need additional information. Thank you for your participation and cooperation.

The materials included will not include individually identifiable health information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended. Consent should be obtained from patients that show full face or specific identifying features that are utilized.*

Yes

I verify I am in compliance with the HIPAA standards to protect the privacy of the patients discussed in my CME Activity(s). I have either received written authorization from the patient, removed any identifiable images or patient records from my presentation, or my presentation does not pertain to patient treatment.*

Yes

Signature - HIPAA Compliance*

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