CONFIDENTIAL
AMERICAN COLLEGE OF RADIOLOGY IMAGING NETWORK
ACRIN 4701
AUTHORIZATION TO RELEASE/DISCLOSE MEDICAL RECORDS TEMPLATE: HIPAA COMPLIANT RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
TO:
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
Street Address
City, State and Zip Code
RE: Patient Name:
Date of Birth:
I authorize and request the disclosure of all protected information from any and all healthcare providers for the purpose of review and evaluation in connection with the ACRIN 4701 trial, entitled RandomizedEvaluation of Patients with Stable Angina Comparing Utilization of Diagnostic Examinations. This clinical trial will be evaluating cost-effectiveness and healthcare utilization following one of two imaging modalities for diagnosis of cardiac-related symptoms. I recognize that by signing this consent, I am allowing the release of medical records related to future healthcare for the purpose of this trial. I understand I will receive a copy of this authorization.
I expressly request that the designated record custodian of all covered entities under HIPAA identified as providing cardiac-related care and care for incidental findings identified during trial-related diagnostic assessment disclose full and complete protected medical information. Information that might identify you will be removed to protect your privacy. Because we do not know exactly what reports will be instrumental in collecting the data needed to support the aims of the trial, all medical records from during the time of trial participation are necessary and are requested, including the following:
All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes; inpatient, outpatient, and emergency room treatment; all clinical charts, reports, order sheets, progress notes, nurses’ notes, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations; medication administration reports; documents, test results, statements, questionnaires/histories, correspondence; and records received by other medical providers.
All physical, occupational, and rehab requests and related consultations.
All claim forms and billing records containing CPT codes related to care for my heart or for treating incidental findings from during my trial-related diagnostic tests including insurance claim forms and itemized bills.
All laboratory, histology, cytology, pathology, autopsy, immunohistochemistry records, and specimens reports; radiology records and films, including (but not limited to) CT, MRI, MRA, PET scans; echocardiogram and cardiac catheterization results.
I understand the medical records to be released or disclosed will include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. This information will be used in the trial analysis only if the information may have impacted your cardiac health. I have the option to refuse to release this protected health information. I understand that if I check the “Yes” box below and add my initials, I am authorizing the release or disclosure of this type of information.
Yes (Initials) No
This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.
You are authorized to release the above records to the following representatives of the American College of Radiology Imaging Network (ACRIN) and its affiliates in the above-entitled matter. Your organization will be reimbursed for copies of the medical record upon receipt of an invoice. If you require prepayment or have questions concerning reimbursement, please contact ACRIN at <phone #>.
American College of Radiology Imaging Network
Name of Representative
ACRIN 4701—Record Procurement Unit
Representative Capacity (e.g., HIM professional, research associate, medical chart abstractor)
1818 Market Street, Suite 1600
Street Address
Philadelphia, PA 19103
City, State and Zip Code
I understand the following: See CFR §164.508(c)(2)(i-iii)
a. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties for the purpose of the clinical trial, or if required by law.
c. My treatment or payment for my treatment will not be impacted by the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until the completion of the research study, approximately 36 months after the signing of this document.
ignature of Patient or Legally Authorized Representative Date
Signature of Patient or Legally Authorized Representative Date
(See 45CFR § 164.508(c)(1)(vi))
Name and Relationship of Legally Authorized Representative to Patient
(See 45CFR §164.508(c)(1)(iv))
Witness Signature Date
ACRIN 4701 1 November 5, 2010