Authorization to Use Protected Health Information for Research

07/23/2018

WinthropUniversity

Authorization to Use Protected Health Information for Research

Purpose of this Form: The Health Insurance Portability and Accountability Act of 1996 (HIPAA; 45CFR Parts 160 & 164) provides protection to you for the use and release of protected health information about you. Under this act, health information about you can not be released to researchers without your written authorization. The researcher(s) identified below is requesting your permission to use health information about you in a research study. Your signature on this form, as well as the Informed Consent form, indicates your willingness to participate in the research study and your permission for the researcher, or research team, to have access to and to use protected health information about you, as identified below. Confidentiality of information will be maintained as stated on the Informed Consent document.

Name of Health Care Provider:

Principal Researcher: Name & Title:

Name(s) & Title(s) of other members of the Research Team:

Title of Research Study:

If you agree to participate in this study as indicated by your signature on this form, you are agreeing to the release of the personal health information as shown below by the checked boxes. This information may include personally identifying information such as your name, address, phone number or social security number.

Entire Medical Record Laboratory ReportsTreatment Records

Photographs Medical Test Reports Tissue and/or Blood Specimens

Other:

Description of how the health information about you will be used in the study:

This authorization expires.

Once this protected health information about you is disclosed to the research team it is no longer protected under the HIPAA and may be disclosed to other institutions or individuals as stated in the Informed Consent.

You may refuse to sign this permission. Refusal to allow health information about you to be used in the study will not affect your ability to receive treatment by the health care provider or your eligibility for benefits.

You may revoke or withdraw your permission in writing at any time by sending written notification to:

Grants and Sponsored Research Development

WinthropUniversity

Rock Hill, SC 29733

Your notice will not apply to actions taken by the researcher or the health care provider prior to the date they receive your written request to revoke authorization.

If you have any questions concerning the research study or the use of personal health information about you, you may contact:

Principal Researcher:

You may also contact:

Grants and Sponsored Research Development

Winthrop University

Rock Hill, SC 29733

PH: 803-323-2460

If you agree to the use and release of personal health information about you, please sign below. You will be given a copy of this form.

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Print name of Individual, Physician or Organization that may receive health information about you.

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Print name of Research ParticipantSignature of Research ParticipantDate

********************************** OR *************************************************

Print name and Title/Relationship of Participant’s Legally Authorized Representative

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Signature of Participant’s Legally Authorized RepresentativeDate