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Authorization for Use and Disclosure of Health Information for Research Purposes

1. You agree to permit the UNIVERSITY OF _______________________, Professor ####### and his/her staff, ("Researchers") conducting the research study [title and description of research study], to use and disclose health information about you to the sponsor of the research [name of sponsor] and representatives of the sponsor [name of organization, e.g., contract research organization] assisting in the research ("Receivers").

2. Your health information to be used and disclosed includes all information about you collected during the research study for research purposes and the health information about you in medical records that is related to the research study. For example, it would include laboratory tests such as your blood counts and tests to measure the function of your liver and kidneys, x-rays or scans, and the following health information and tests: ________________________________________________________________________________________
________________________________________________________________________________________

3. Your health information may also be disclosed to reviewed by an institutional review board, and representatives of government agencies, including the Food and Drug Administration (FDA) [and the Office of Human Research Protections, if applicable] and for the following purposes: __________________________________________________________________________________________
If your health information is required for these research purposes, the reviewers may need your entire medical record.

4. Health information about you may also be used to create information that does not identify you. The de- identified data may be used and released by Researchers, including use for other research purposes.

5. This health information about you may be further disclosed by the Receivers of the information. If disclosed by them, the information may no longer be covered by federal or state privacy regulations.

6. Information collected about you for purposes of this research study may be kept in a research study record separate from your medical records. You will not be able to obtain your research study record until the end of the study.

7. In order to participate in this research study, you must sign this Authorization. However, you cannot be denied medical treatment because you did not sign this Authorization.

8. This Authorization has no expiration date.

9. You have the right to revoke this Authorization at any time by a written notification to the Researchers' Privacy Contact __________________________________________________________________________. If you revoke this Authorization, you will no longer be allowed to participate in the research. Also, even if you revoke this Authorization, the Researchers may still use and disclose the health information that they have already obtained as necessary to maintain the reliability of the research.

________________________________   ______________
Signature of Research Participant          Date

________________________________
Print Name of Research Participant

For Personal Representative of the Research Participant (if applicable)

Print Name of Personal Representative: _______________________________________
Personal Representative Relationship or Authority: ______________________________

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