University of Miami - Office of HIPAA Privacy and Security |
PO BOX 019132 (M879) hipaaprivacy@med.miami.edu |
Miami, FL 33101 (305) 243-5000 |
AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION |
Form D3901001E Revised 11/10/14 |
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MRN: | {{cpr.participant.empi}} |
DOB: | {{cpr.participant.birthDate | date: global.dateFmt}} |
Name | {{cpr.participant.lastName}}, {{cpr.participant.firstName}} |
DOB | {{cpr.participant.birthDate | date: global.dateFmt}} |
Gender | {{cpr.participant.gender}} |
Medical Record # | {{cpr.participant.pmis | osArrayJoin: pmiText}} |
HIPAA Research Authorization Template – Form B.
AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION.
I agree to permit the University of Miami Jackson Health System both, and any of my doctors or other health care providers (together “Providers”), Principal Investigator and [his/her/their/its] collaborators and staff (together “Researchers”), to obtain, use and disclose health information about me as described below. Authorized staff not involved in the study may be aware that I am participating in a research study and may have access to my information. If the study is related to my medical care, any study-related information may be placed in my permanent hospital, clinic or physician’s office records.
4. The Sponsor and any applicable Cooperative Groups may use and share my health information for purposes of the Research, data safety and monitoring and as permitted by the consent form. Contract Research organization(s):
5. Once my health information has been disclosed to a third party, ffederal privacy laws may no longer protect it from further disclosure.
6. I hereby authorize the Sponsor to observe any medical procedures I undergo as part of the Research. Please note that:You do not have to sign this Authorization, but if you do not, you may not participate in the Research. If you do not sign this authorization, your right to other medical treatment will not be affected.
You may change your mind and revoke (take back) this Authorization at any time and for any reason. To revoke this Authorization, you must write to either of the following:
*Research Study Personnel Name: Nipun Merchant, MD, PhD
Address: 1550 NW 10th Avenue, Fox 436, Miami, FL 33136
Tel. No.: 305-243-6777
Human Subjects Research Office
Address: 1400 NW 10th AVE, Suite 1200A Miami, FL 33136
Tel. No.: (305) 243-3195
However, if you revoke this Authorization, you will not be allowed to continue taking part in the Research. Also, even if you revoke this Authorization, the Providers, Researchers, any applicable Cooperative Groups and the Sponsor may continue to use and disclose the information they have already collected to protect the integrity of the research or as permitted by the Informed Consent Form.
While the Research is in progress, you may not be allowed to see your health information that is created or collected by the University of Miami Jackson Health System both,in the course of the Research. After the Research is finished, however, you may see this information as described in the University of Miami Jackson Health System both , Notice of Privacy Practices.
*Study personnel must send copies of participant revocations to:
Office of HIPAA Privacy and Security AND the Human Subjects Research Office.
8. This Authorization does not have an expiration (ending) date. There is no set date at which your information will be destroyed or no longer used. This is because the information used and created for the study may be analyzed for many years, and it is not possible to know when this will be complete.
9. You will be given a copy of this Authorization after you have signed it.