Authorization for Release of Personal Health Information
(Protected Health Information) for Research Purposes
Please correct the errors described below.
This Authorization for Release of Personal Health Information is a required supplement to theInformed Consent Form under the Health Insurance Portability and Accountability Act. The HIPAAPrivacy Rule protects the privacy of personal health information contained in your medical records(defined as “protected health information” by HIPAA). Spectrum Clinical Research has to obtain this separate Authorization from you so it can use your personal health information for the research described in the Informed Consent Form. This Authorization is voluntary and you have the right to refuse to sign it. You may revoke this Authorization at any time by providing a written notice of revocation; however, such revocation would not affect any action taken by Spectrum Clinical Research in reliance on this Authorization before receipt of your written revocation.
By signing this document, you agree to the release of certain personally identifiable health information from your medical record BY:
The Principal Investigator, Sub-Investigator, and other members of the research team
Spectrum Clinical ResearchVersion
For the research purposes described in the attached Informed Consent Form and to the research sponsor and government agencies as required to monitor the research.
You are authorizing the release of the following protected health information:
By signing this Authorization you agree that you have read this Authorization form and that you havebeen given the opportunity to ask questions. If you do not sign this Authorization you cannotparticipate in the research study. You may contact us at any time with questions.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
DISCLAIMER:By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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