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<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
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<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.7"/>
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<templateId root="2.16.840.1.113883.10.20.1"/>
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<id extension="BPPC-2026-001" root="2.25.123456789012345678901234567890"/>
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<code code="57016-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Privacy Policy Acknowledgement Document"/>
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<title>Patient Privacy Consent Acknowledgement</title>
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<effectiveTime value="20260225143000-0500"/>
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<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="Normal"/>
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<languageCode code="en-US"/>
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<recordTarget>
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<patientRole>
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<id extension="PATIENT12345" root="2.16.840.1.113883.3.933"/>
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<addr use="HP">
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<streetAddressLine>123 Main Street</streetAddressLine>
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<city>Boston</city>
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<state>MA</state>
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<postalCode>02101</postalCode>
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<country>USA</country>
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</addr>
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<telecom use="HP" value="tel:+1-617-555-0123"/>
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<telecom use="HP" value="mailto:john.doe@example.com"/>
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<patient>
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<name use="L">
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<given>John</given>
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<given>Michael</given>
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<family>Doe</family>
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</name>
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<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
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<birthTime value="19850315"/>
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</patient>
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<providerOrganization>
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<id root="2.16.840.1.113883.3.933.1"/>
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<name>Connectathon Memorial Hospital</name>
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<telecom value="tel:+1-617-555-1000"/>
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<addr>
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<streetAddressLine>456 Hospital Drive</streetAddressLine>
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<city>Boston</city>
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<state>MA</state>
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<postalCode>02102</postalCode>
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</addr>
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</providerOrganization>
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</patientRole>
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</recordTarget>
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<author>
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<time value="20260225143000-0500"/>
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<assignedAuthor>
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<id extension="PATIENT12345" root="2.16.840.1.113883.3.933"/>
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<addr use="HP">
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<streetAddressLine>123 Main Street</streetAddressLine>
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<city>Boston</city>
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<state>MA</state>
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<postalCode>02101</postalCode>
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</addr>
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<telecom use="HP" value="tel:+1-617-555-0123"/>
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<assignedPerson>
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<name>
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<given>John</given>
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<given>Michael</given>
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<family>Doe</family>
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</name>
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</assignedPerson>
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</assignedAuthor>
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</author>
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<custodian>
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<assignedCustodian>
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<representedCustodianOrganization>
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<id root="2.16.840.1.113883.3.933.1"/>
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<name>Connectathon XDS Repository</name>
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<telecom value="tel:+1-617-555-1000"/>
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<addr>
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<streetAddressLine>456 Hospital Drive</streetAddressLine>
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<city>Boston</city>
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<state>MA</state>
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<postalCode>02102</postalCode>
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</addr>
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</representedCustodianOrganization>
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</assignedCustodian>
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</custodian>
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<legalAuthenticator>
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<time value="20260225143000-0500"/>
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<signatureCode code="S"/>
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<assignedEntity>
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<id extension="PATIENT12345" root="2.16.840.1.113883.3.933"/>
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<addr use="HP">
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<streetAddressLine>123 Main Street</streetAddressLine>
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<city>Boston</city>
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<state>MA</state>
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<postalCode>02101</postalCode>
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</addr>
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<telecom use="HP" value="tel:+1-617-555-0123"/>
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<assignedPerson>
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<name>
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<given>John</given>
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<given>Michael</given>
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<family>Doe</family>
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</name>
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</assignedPerson>
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</assignedEntity>
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</legalAuthenticator>
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<component>
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<structuredBody>
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<component>
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<section>
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<code code="57017-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Privacy Policy Organization Document"/>
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<title>Patient Privacy Consent</title>
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<text>
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<paragraph>
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<content styleCode="Bold">Affinity Domain:</content> Connectathon Affinity Domain </paragraph>
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<paragraph>
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<content styleCode="Bold">Consent Policy:</content> OPT-IN Patient Privacy Consent Policy </paragraph>
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<paragraph>
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<content styleCode="Bold">Policy Description:</content>
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</paragraph>
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<paragraph> In this Connectathon Affinity Domain, healthcare data is contained exclusively in documents shared via the XDS.b, XDR, or XDM profiles, and the confidentialityCode is contained in a document's XDS metadata. </paragraph>
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<paragraph> The patient agrees to the default privacy consent policy. </paragraph>
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<paragraph> The Patient also agrees to share documents with a confidentialityCode of "R" (Restricted). </paragraph>
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<paragraph>
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<content styleCode="Bold">Effective Date:</content> February 25, 2026 </paragraph>
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<paragraph>
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<content styleCode="Bold">Expiration Date:</content> December 31, 2026 </paragraph>
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<paragraph>
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<content styleCode="Bold">Patient Signature:</content> John Michael Doe </paragraph>
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<paragraph>
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<content styleCode="Bold">Date Signed:</content> February 25, 2026 at 2:30 PM EST </paragraph>
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</text>
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<entry typeCode="DRIV">
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<consent classCode="CONS" moodCode="EVN">
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<id extension="CONSENT-2026-001" root="2.25.987654321098765432109876543210"/>
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<code code="OPTIN" codeSystem="2.16.840.1.113883.3.445.21" displayName="Opt-In Consent"/>
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<statusCode code="completed"/>
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<effectiveTime>
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<low value="20260225000000-0500"/>
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<high value="20261231235959-0500"/>
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</effectiveTime>
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<policyCode code="1.3.6.1.4.1.21367.2006.7.108" codeSystem="1.3.6.1.4.1.21367.2017.3" codeSystemName="Connectathon Consent Policy Codes" displayName="OPT-IN"/>
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<participant typeCode="COVBY">
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<participantRole classCode="PAT">
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<id extension="PATIENT12345" root="2.16.840.1.113883.3.933"/>
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<code code="R" codeSystem="2.16.840.1.113883.5.25" codeSystemName="Confidentiality" displayName="Restricted"/>
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</participantRole>
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</participant>
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<participant typeCode="SUBJ">
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<participantRole classCode="PAT">
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<id extension="PATIENT12345" root="2.16.840.1.113883.3.933"/>
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<playingEntity>
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<name>
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<given>John</given>
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<given>Michael</given>
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<family>Doe</family>
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</name>
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</playingEntity>
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</participantRole>
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</participant>
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</consent>
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</entry>
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</section>
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</component>
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</structuredBody>
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</component>
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</ClinicalDocument>
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