University of
Department of
[identify department]
Authorization
to Collect, Use, and/or Disclose
Identifiable
Health Information
For a Research
Database
1.
Why am I being
asked to sign this form? We want your
permission to collect private or protected health information about you and our
treatment of you for a research database that we keep.
2.
What information
do you want to collect? We will keep
your name, birthdate, address, zip code, gender,
race/ethnicity, diagnosis, treatment information and dates, and results.
3.
Why do you want this information? We will use this information to help us plan
or conduct new research studies.
4.
Who will be able
to use this information? This
information will be used by your treating physician and may also be given to
other researchers working with your treating physician to plan new research
studies.
5.
Will my
information be kept private? Yes, this
information will be kept private. Your
treating physician and those working with your treating physician,
will be allowed to see or use it, as described above. The Food and Drug Administration, the Office
for Human Research Protections, and the University of
Mississippi Medical Center’s Institutional Review Board and Office of
Compliance may also review the information.
Your medical information and records, once disclosed, may be
re-disclosed by any of the recipients identified above and may no longer be
protected by the Privacy Standards of the Health Insurance Portability and
Accountability Act (HIPAA), which is a federal regulation designed to protect
medical information, including medical information and records created through
research.
6.
Do I have to
sign this form? No, you do not have to
sign this form. If you do not sign it we
will not be able to use your protected health information, as described above,
but it will not affect your care in any way.
7.
What if I sign
this form but then change my mind? You
can change your mind at any time and withdraw this permission. To withdraw your permission you must notify
us in writing, by contacting [insert UMC contact name, address, and
telephone number].
8.
How long will
this permission last? This permission [has
no expiration date] [will expire_______].
_____________________________________________________________
Name of Participant or Participant’s Legally
Authorized Representative
_____________________________________________________________
Signature of Participant or Participant’s Legally
Authorized Representative
_____________________________________________________________
Legally Authorized Representative’s Right to Act
_______________________
Date