Authorization for Release of Personal Health Information

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.

PATIENT INFORMATION

Last Name (Per Social Security card)

First Name

Middle Initial

Date of Birth

Social Security Number

Telephone #

Street Address

City

State

Zip Code

By signing this document, you agree to the release of certain personally identifiable health information from your medical record BY:

Healthcare Provider

Clinic/Institution Name

Address:

City, State

Zip Code

Tel:

Fax:

TO:

Spectrum Clinical Research

The Principal Investigator, Sub-Investigator, and other members of the research team

Other:

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:

All Medical Records (Including super confidential information)

Current Medication List

Past Medical History Forms

Last Complete Physical Exam

Last 1-2 Progress Notes with mention of diagnosis of

Other:

This Authorization will expire at the end of the research study

This Authorization has no expiration date

Authorization

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.

Subject Signature

Date

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.

Witness Signature

Date

Your information will be encrypted.