ࡱ> 8:7q bjbjt+t+ " AA]8888888LLLLL XLXZZZZZZ$0~8~88 88XLL8888Xj88Xt 0LL BMARQUETTE UNIVERSITY (This form is a suggested guideline for Researchers) Authorization to Use or Disclose Protected Health Information in Research Written authorization from the patient is required by law. All items must be complete to be considered valid. Print Name of Research Participant ___________________________________________Date of Birth: ____/_____/______ I authorize the use and/or disclosure of Protected Health Information (Health Information) as described below. Name of person or organization authorized to use, release or disclose the Health Information: ______________________________________________________________________________________________ Name of Principal Investigator and his/her Research Team authorized to receive the Health Information: ___________ _______________________________________________________________________________________________ Name of Other Organization(s) authorized to receive the Health Information (for example Study Sponsor, Institutional Review Board, or Government Agencies): _____________________________________________________________ _______________________________________________________________________________________________ Description of Health Information to be released (for example Research Medical Records, all Medical Records, Laboratory Reports, Results of Psychological Examinations, etc.): __________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ This Health Information is being released to conduct the Research Study (IRB #, Title, and Purpose): ______________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ The information to be released may include information relating to the diagnosis and/or treatment of mental illness, alcohol/drug abuse, HIV test results, developmental disabilities, and genetic testing results unless I give written instructions not to release such information. I have the right to cancel or revoke this authorization at any time. If I want to cancel this authorization, I must do so in writing and present it to the Principal Investigator or his/her Research Team. I understand that the cancellation (revocation) may not apply to information that has already been released, or if it would interfere with the integrity of the study. I have a right to inspect and/or receive a copy of the Health Information to be released and that I may be charged for any copies of the records that I receive. Access to health information created or obtained for this research study may be temporarily suspended until the study has been completed. Once the study is completed, I will again have access to my health information. If I agree to sign this authorization, I must be provided with a signed copy of this form. If no prior notice to revoke this authorization is received, this authorization will expire on (select one): ( At the end of the study ( _________Years after the end of the study ( ________________________ (enter specific date) The information disclosed may be redisclosed by the recipient and may no longer be protected by the Federal privacy rules. I may refuse to sign this authorization, and that my refusal to sign will not affect my ability to obtain non-study related treatment. If additional Health Information is required other than what has been identified above, another authorization form must be completed and signed. ____________________________________________________ ___________________________________ Signature of Participant or Legal Representative Date ____________________________________________________ ________________________________________________ If signed by Legal Representative, Relationship to Participant Signature of Witness If you wish to construct your own form, use the guidelines provided by the NIH at: HYPERLINK "http://privacyruleandresearch.nih.gov/authorization.asp"http://privacyruleandresearch.nih.gov/authorization.asp Juxcd~"uv0Jj56CJU 56CJj56CJU56 jCJCJCJ6CJ>*6>*CJ JKvxFG{|VW T  & F & FJKvxFG{|VW T U * + abjkFGH !"u                                     ET U * + abjk & F & F & FFGH !"u 1h/ =!`"`#$%DyK yK phttp://privacyruleandresearch.nih.gov/authorization.asp [8@8 NormalCJ_HaJmH sH tH <A@< Default Paragraph Font,B@, Body Text$a$(U@( Hyperlink>*B*8V@8FollowedHyperlink>*B*   T   uXMarquette UniversityeC:\Documents and Settings\piacsekp\Application Data\Microsoft\Word\AutoRecovery save of Document1.asdMarquette UniversityFC:\Documents and Settings\piacsekp\My Documents\HIPPAauthorization.docMarquette UniversityFC:\Documents and Settings\piacsekp\My Documents\HIPPAauthorization.docMelissa J. LauritchZC:\Documents and Settings\lauritchm\Desktop\HIPPA Authorization to Use or Disclose PHI.docMelissa J. Lauritch1A:\HIPPA Authorization to Use or Disclose PHI.docMarquette University,C:\WINDOWS\Desktop\AuthorizationResearch.docMarquette University,C:\WINDOWS\Desktop\AuthorizationResearch.docMarquette University,C:\WINDOWS\Desktop\AuthorizationResearch.docMarquette University,C:\WINDOWS\Desktop\AuthorizationResearch.docMarquette University,C:\WINDOWS\Desktop\AuthorizationResearch.docZkPO*^`nr6RHRFC] {G 1eMG6}9kYs Qwo hh56CJ.)88)()()pp()  .@ @ .  . hh56CJ.)88)()()pp()  .@ @ .  . ^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. hh56CJ.)88)()()pp()  .@ @ .  .^`o()^`.L^`L.  ^ `.[[^[`.+L+^+`L.^`.^`.L^`L. hh56CJ.)88)()()pp()  .@ @ .  .hhCJo(.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. {GQwnr6eMG9kYsFCPO*Zk@daa`@GTimes New Roman5Symbol3& ArialQ Wingdings 2Webdings"hڪzF+{f|zft !r0d,[Template Form for Authorization to Use or Disclose Protected Health Information in ResearchMarquette UniversityMarquette University Oh+'00<HX x    \Template Form for Authorization to Use or Disclose Protected Health Information in ResearchempտƵhorarqarqNormaltտƵhor6rqMicrosoft Word 8.0y@ @%j@e@it  ՜.+,D՜.+,X hp  8տƵu,1 \Template Form for Authorization to Use or Disclose Protected Health Information in Research Titled(RZ _PID_GUID _PID_HLINKSAN{B1153D3E-ED5A-418A-9621-2640236C4306}Al-8http://privacyruleandresearch.nih.gov/authorization.asp  !"#$%&()*+,-.01234569Root Entry Fo0;Data 1TableWordDocument" SummaryInformation('DocumentSummaryInformation8/CompObjjObjectPool00  FMicrosoft Word Document MSWordDocWord.Document.89q