Form 5 Authorization to Release Medical Records

Attachment 11: Authorization to Release Medical Records

Form Approved
OMB No. 0925-0407
Exp. Date xx/xx/20xx

PROSTATE, LUNG, COLORECTAL, AND OVARIAN (PLCO) CANCER
SCREENING TRIAL FOLLOW-UP STUDY
CENTRAL DATA COLLECTION CENTER (CDCC)
Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Branch
Office, 6705 Rockledge Drive, MSC 7974 Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION FOR RESEARCH
Participant Name: <> <>
PID: <>

Date of Birth: <> Gender: <>

Please read this form and provide information listed in this box for the appropriate Medical Provider and/or
institution to contact for your medical records.
Name of the doctor who diagnosed this cancer:___________________________________
Name of the Institution where cancer was diagnosed:
Street Address: _________________<> __________________________
City: _____ <> _________State: _____ <> ___Zip Code:
Telephone: _(<<###>>)_ _<<###>>_ – __

<>

<<####>>___________

Name of the doctor who treated this cancer:___________________________________
Name of the Institution where cancer was treated:
Street Address: _________________<> __________________________
City: _____ <> _________State: _____ <> ___Zip Code:
Telephone: _(<<###>>)_ _<<###>>_ – __ <<####>>___________

<>

I hereby authorize the above referenced medical provider to release my protected health information,
including copies of my medical and hospital records, pathology slides, or tissue blocks related to the diagnosis
and treatment of _______<>______ cancer to research staff at the Central Data Collection
Center (CDCC), Westat, who are working on the study entitled Prostate, Lung, Colorectal and Ovarian (PLCO)
Cancer Screening Trial Extended Follow-up Study. This study is being conducted by the National Cancer
Institute (NCI). My individual health information that may be used or disclosed includes medical health data,
full or abstracted records, slides or tissue blocks released after the date of my signature.
1

Form Approved
OMB No. 0925-0407
Exp. Date xx/xx/20xx

PROSTATE, LUNG, COLORECTAL, AND OVARIAN (PLCO) CANCER
SCREENING TRIAL FOLLOW-UP STUDY
CENTRAL DATA COLLECTION CENTER (CDCC)
(Continued with Signature on page 2)
It is my understanding that this information will be used for research purposes only and no individual will ever
be identified in any published report. I understand that I may revoke this authorization at any time with
written notification to the Participant Support Coordinator at PLCO CDCC, Westat, 1600 Research Blvd, Room
GA-L60, Rockville, Maryland 20850, to inform the research team of my decision, but that the revocation will
not have any effect on the information released, used or disclosed, or collected by the study prior to
notification of revocation. This authorization does not have an expiration date.
I understand that once my health information is disclosed under this authorization, there is potential for redisclosure of my medical information and my medical information may not be subject to privacy rule
protections; therefore the facility listed above is released from any and all liability resulting from re-disclosure.
I have been informed that I do not have to sign this Authorization. My decision not to sign the Authorization
will not affect any other treatment, payment, or enrollment in health plans, cancer research studies, or
eligibility for benefits.
A photocopy/fax of this authorization will be treated in the same manner as an original.
I am the research participant or personal representative authorized to act on behalf of the participant. I have
read this information and I have received a copy of this authorization form.
_____________________________________
(PARTICIPANT’S SIGNATURE)
_____________________________________
(PRINT PARTICIPANT’S FULL NAME)

________________
(DATE)

_____________________________________
(PERSONAL REPRESENTATIVE’S SIGNATURE)
_____________________________________
(PRINT PERSONAL REPRESENTATIVE’S FULL NAME)

________________
(DATE)

_________________________________________________
(Relationship or authority to act on behalf of the participant)
Reason for Personal Representative Signature:
2

Participant Disabled

Participant Deceased