ࡱ> GIF` +"bjbjss 08ILLL`$,`=.///$khL~^/~~:::~lL:~:::, ,L8 F)J$  0=. m Fm 8m L8h/0_":///*///=~~~~```d ``````  ID #_________________ HIPAA RESEARCH AUTHORIZATION Authorization for the Creation, Use, and Disclosure of Protected Health Information for Institutional Review Board Approved Research Instructions: This authorization should be attached to each Informed Consent Form. Investigators: Please complete information fields below and questions 2-8. Leave the name of research subject and signature areas blank. Title of Study: ________________________________________________________________________ Name of Principal Investigator: __________________________________________________________ Phone Number: ____________________________ Sponsor: __________________________________ IRB Protocol Number: _______________________ Protocol Approval Date: This form authorizes 911Թ (TC) to use and disclose certain protected health information about _______________(Name of research subject)_____________________________________ that we will collect and create in this research study.  This authorization is voluntary, and you may refuse to sign this authorization. If you s If you sign this form, you are agreeing that TC may use and disclose protected health information collected and created in this research study. The specific health information and purpose of each use and disclosure are:  Health Information Purpose(s) (Check as applicable) (Enter matching letter(s) from Purpose Categories) __Medical records ____________________________ __X-ray/MRI/CT/Diagnostic _____________________________ Images __Photographs, videotapes, or digital or other images _____________________________ __Questionnaires, interview results, focus group survey, psychology survey, behavioral performance tests (e.g., memory & attention) _____________________________ Other: If the information to be used or disclosed contains any of the types of records or information listed below, additional laws relating to use and disclosures of the information may apply. You understand and agree that this information will be used and disclosed only if you place your initials in the applicable space next to the type of information. (Investigators please type N/A in irrelevant fields). ___AIDS or HIV infection information ___Drug/alcohol diagnosis, treatment, or referral information ___Mental or behavioral health or psychiatric care ___Genetic testing information The persons who are authorized to use and disclose this information are: ___All the investigators listed on page one of the Research Consent Form ___Others at TC who are participating in the conduct of this research protocol: ___The TC Institutional Review Board The persons who are authorized to receive this information are: __ The sponsor of this study: __ Federal or other governmental agencies responsible for research oversight: __ Others: Protected health information that we collect from you in this study will be kept by us until: ___ The study is completed ___ Indefinitely __ Other: You have the right to revoke this authorization and can withdraw your permission for us to use your information for this research by sending a written request to the Principal Investigator listed on page one of the research consent form. If you do send a letter to the Principal Investigator, the use and disclosure of your protected health information will stop as of the date he/she receives your request. However, the Principal Investigator is allowed to use information collected before the date of the letter or collected in good faith before your letter arrives. Revoking this authorization will not affect your health care or your relationship with TC. If we have disclosed your protected health information outside of TC, to persons or agencies identified in item #5 above, it is possible that this information could be released again without your permission. TC tries to protect against this by being very careful in releasing your information. The ways in which we will limit the further release of your protected health information are: ___ Contractual agreements with those who may not receive the information ___ Not releasing your information in a way that could identify you ___ Other: We will use this information for research purposes only. Any information we get from you or your health records will be identified by a number only, not by your name.  ____________________________________________________________________________________ Printed name of research subject or subjects representative __________________________________________ _______________________________ Signature of subject or subjects representative Date Description of Relationship to subject: _______________________________________________________ This HIPAA Research authorization form must be used exactly as it is presented here. Any alteration or editing of the form will render it unapproved for research use at TC. The use of an unapproved research consent /authorization form will require that any data collected from subjects who received such a form, must be excluded. This authorization is voluntary, and you may refuse to sign this authorization. If you refuse to sign this authorization, your health care and relationship with your provider and with TC will not be affected; however, you will not be able to enter this research study. Note: We will use this information for research purposes only. Any information we get from you or your health records will be identified by a number only, not by your name. Purpose Categories To learn more about the condition/disease being studied To learn more about the costs of treating the condition/disease being studied To improve health care for persons with the condition/disease being studied To analyze research results To facilitate treatment, payment, and operations related to the study To complete research obligations in this study To comply with federal or other governmental agency regulations To monitor for adverse events/side effects To determine the safety and effectiveness of the treatment(s) To perform quality assessments related to research at TC To teach TC students To place in a repository or bank for future research purposes Other ___________________________________ You will receive a copy of this authorization form after you sign it. 8 " $ % &    V W X e 6  ¸®®®¤†šš{oeh5B*phh|,5B*CJphh'h9 B*phh'5B*phhy`5B*phhO5B*phh9 5B*phh|,5B*phh#5B*phh9 5B*phh9 5>*B*phh9 h9 5OJQJh#5OJQJhJ,5OJQJh5OJQJ%78 X   b c d e $h^ha$gdy`$a$$^a$$a$$a$$a$gdgdI*"   c g < ? 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