Miami_HIPAA_Form_English

IRB Protocol Number:20070461

Principal Investigator:Neil Schneiderman, PhD

Departmental Study Code:

HIPAA Research Authorization Template – Form B
AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
University of Miami
Jackson Health System
both, and any of my
I agree to permit the
doctors or other health care providers (together “Providers”), Principal Investigator and [his /her/their/its]
collaborators and staff (together “Researchers”), to obtain, use and disclose health information about me as
described below.
1. The health information that may be used and disclosed includes: all information collected during the
research and procedures described in the Informed Consent Form for





the Research as described in the accompanying Informed Consent Form (“the Research”); and
health information in my medical records that is relevant to the Research, includes my past medical history
including medical information from my primary care physician and other medical information relating to
my participation in the study; and
health information in my medical records pertaining to HIV status, including my HIV test results (if
applicable).

2. The Providers may disclose health information in my medical records to:

the Researchers;

representatives of government agencies, any applicable Cooperative Groups, review boards, and other
persons who watch over the safety, effectiveness, and conduct of research; and


the sponsor of the Research, National Institutes of Health

,

(Print Sponsor Name)

and its agents and contractors (together “Sponsor”).
3. The Researchers may use and share my health information:

among themselves, with the Sponsor, with any applicable Cooperative Groups, and with other participating
Researchers to conduct the Research; and

as permitted by the Informed Consent Form.
4. The Sponsor and any applicable Cooperative Groups may use and share my health information for
purposes of the Research and as permitted by the consent form.
5. Once my health information has been disclosed to a third party, federal privacy laws may no longer protect
it from further disclosure.
6. Please note that:
You do not have to sign this Authorization, but if you do not, you may not participate in the Research. If you
do not sign this authorization, your right to other medical treatment will not be affected.

University of Miami - Office of HIPAA Privacy and Security
PO BOX 019132 (M879)
[email protected]
Miami, FL 33101
(305) 243-5000

AUTHORIZATION TO USE AND DISCLOSE
HEALTH INFORMATION
Form
D3901001E
Revised
03/27/06

Required Information: Please Complete.

NAME:
MRN:
SS #

IDX
DL #

PASSPORT #

OTHER

DOB:

/

SMS

ID#:
AGE:

/

DATE OF SERVICE: _________/_________/_________
 2003 University of Miami

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IRB Protocol Number: 20070461

Principal Investigator:Neil Schneiderman, PhD

Departmental Study Code:

You may change your mind and revoke (take back) this Authorization at any time and for any reason.
To revoke this Authorization, you must write to either of the following:
*Research Study Personnel Name: Dr. Marc Gellman
Address: 1120 NW 14th Street, Room 1518, Miami, FL 33136
Tel. No.: 305-243-2044
Human Subjects Research Office
Address: 1500 NW 12th AVE, Suite 1002 Miami, FL 33136
Tel. No.: (305) 243-3195

However, if you revoke this Authorization, you will not be allowed to continue taking part in the Research.
Also, even if you revoke this Authorization, the Providers, Researchers, any applicable Cooperative Groups and
the Sponsor may continue to use and disclose the information they have already collected to protect the integrity
of the research or as permitted by the Informed Consent Form.
While the Research is in progress, you may not be allowed to see your health information that is
University of Miami
Jackson Health System
both, in the
created or collected by the
course of the Research. After the Research is finished, however, you may see this information as
described in the
Privacy Practices.

University of Miami

Jackson Health System

both, Notice of

*Study personnel must send copies of participant revocations to:
Office of HIPAA Privacy and Security AND the Human Subjects Research Office.

7. This Authorization does not have an expiration (ending) date.
8. You will be given a copy of this Authorization after you have signed it.
_______________________________________

______________________________________

Signature of participant or participant’s legal representative

Date

_______________________________________

______________________________________________
Printed name of legal representative (if applicable)

Printed name of participant

______________________________________
Representative’s relationship to participant

Study personnel must send copy with signature to the Office of HIPAA Privacy and Security
For questions, contact the Human Subjects Research Office at 305-243-3195.
University of Miami - Office of HIPAA Privacy and Security
PO BOX 019132 (M879)
[email protected]
Miami, FL 33101
(305) 243-5000

AUTHORIZATION TO USE AND DISCLOSE
HEALTH INFORMATION

Required Information: Swipe Keyplate if available and leave the box blank.

NAME:
MRN:

Form
D3901001E
Revised
03/27/06

IDX

SMS

SS:
AGE:
DATE OF SERVICE:
© 2003 University of Miami

DOB:

/
/

/
/
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