Appendix 10e Miami HCHS English version

IRB Protocol Number:

20131007

Principal Investigator: Neil Schneiderman

Departmental Study Code: Psychology

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. Authorized staff not involved in the study may be aware that I am participating in a research study and may
have access to my information. If the study is related to my medical care, any study-related information may be
placed in my permanent hospital, clinic or physician’s office records.
1. The health information that may be used and disclosed may include:
All information collected during the research and procedures described in the Informed
consent Form for the Research as described in the accompanying study specific 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
[The following checked boxes must be separately initialed by you in order to permit access to these records]
_____
HIV / AIDS status.
HIV-related information, which includes any information indicating that I have had an
HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information
which could indicate that I have been potentially exposed to HIV.
______
Sexually transmitted diseases (STD’s).
______
Mental health treatment records governed under state law (including mental health
records relating to involuntary or voluntary mental health treatment).
Mental health records may include substance abuse information .
______
Substance abuse (drug and alcohol) treatment records.
Substance abuse information may be part of the mental health records.
______
Sexual assault information.
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, NIH/NHLBI,
and its agents, monitors and contractors (together “Sponsor”).
3. The Researchers may use and share my health information:

among themselves, with the Sponsor, with any applicable Cooperative Groups, health care facilities, research
sites, independent data and safety monitoring boards, study monitors and with other participating Researchers
(internal and/or external) to conduct the Research;

Federal and State agencies that have oversight of the study or whom access is required under the law. These may
include FDA, OHRP, NIH and Florida DOH; and

as permitted by the Informed Consent Form.
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
12/10/10

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: 20131007

Principal Investigator: Neil Schneiderman

Departmental Study Code:Psychology
4. The Sponsor and any applicable Cooperative Groups may use and share my health information for purposes of the
Research, data safety and monitoring and as permitted by the consent form.
Contract Research organization(s): NIH/NHLBI
5. Once my health information has been disclosed to a third party, federal privacy laws may no longer protect it from
further disclosure.
6. I hereby authorize the Sponsor to observe any medical procedures I undergo as part of the Research.
7. 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.
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: Maria Pattany
Address: Univeristy of Miami, 1120 N.W. 14th Street, room 733, Miami, FL 33136
Tel. No.: 305-243-1438
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 course of the
created or collected by the
Research. After the Research is finished, however, you may see this information as described in the
University of
Miami
Jackson Health System
both, Notice of Privacy Practices.
*Study personnel must send copies of participant revocations to:
Office of HIPAA Privacy and Security AND the Human Subjects Research Office.

8. This Authorization does not have an expiration (ending) date. There is no set date at which your information will be
destroyed or no longer used. This is because the information used and created for the study may be analyzed for many
years, and it is not possible to know when this will be complete.
9. 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

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

NAME:
MRN:

AUTHORIZATION TO USE AND DISCLOSE
HEALTH INFORMATION

IDX

SMS

SS:

Form
D3901001E
Revised
12/10/10

AGE:
DATE OF SERVICE:
© 2003 University of Miami

DOB:

/
/

/
/
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