HIPPA Authorization to Use and/or Disclose

"Authorization to Use and/or Disclose Protected Health Information (PHI) for Research" form.
This form is applicable whenever a research (study) consent form is used as part of your study. It must be signed by all new research participants consented on 4/14/03 or later. (However, participants accrued prior to that date do not need to sign this "Authorization", unless they are re-consented for any reason on or after 4/14/03 and have not previously signed the "Authorization" form). Be sure to insert study-specific information prior to submitting for IRB approval.

Authorization to Use and/or Disclose Protected Health Information (PHI) for Research Form