NOTE: Click here for more information on required elements of HIPAA Authorization Forms.
By my signature below, I authorize [Insert name of person or class of persons who may make the disclosure, generally, the health care provider] to release to [Insert name of Principal Investigator and research staff, department, University of Oregon] the following medical records:
[Note: this list should be tailored specifically to your research and state precisely which records are being requested. Delete what does not apply and include additional records as needed.]
___ Demographic information, including your name, address, phone number . . .
___ Information in your medical records related to . . .
___ X-rays/laboratory results obtained by ____ laboratory.
___ Information from mental health records.
___ Other:________________________________
We will use the medical records containing your personal health information to . . . [Insert purpose statement from the Informed Consent form and describe each use of the information.]
[Choose one of the following sentences that best describes your time frame and delete the other two]
This authorization will expire on (date).
This authorization will expire at the end of the research study.
This authorization will not have an expiration date.
This authorization can be revoked at any time by delivering a revocation in writing to the Health Care Provider named above and that the revocation will be effective except to the extent (1) research has already been conducted in reliance on my previous authorization or (2) if necessary to protect the integrity of the research (e.g., to account for a person's withdrawal from the research).
I realize that [name of Principal Investigator] may not be bound by the Privacy Rule and therefore may not be required by that Rule to maintain the confidentiality of my personal health information.
The researchers can only use or disclose your health information for purposes approved by the Institutional Review Board at the University of Oregon or as required by law or regulations and will continue to protect your personally identifiable health information as described in the attached Informed Consent Form.
I understand that if I refuse to sign this form I will be [describe consequences, i.e. excluded from the research] but that my relationship with [health care provider] will not be affected.
I understand what this document says and authorize release of my personal health information as stated above. I understand I will be given a signed copy of this Authorization for my records.
[The research participant should sign and date this form. If the research participant is a minor, the legally authorized representative should sign and date this form.]
