University of Mississippi Medical Center

Department of [identify department]

Authorization to Collect, Use, and/or Disclose

Identifiable Health Information

For a Research Database

 

1.                        Why am I being asked to sign this form?We want your permission to collect private or protected health information about you and our treatment of you for a research database that we keep.

 

2.                        What information do you want to collect?We will keep your name, birthdate, address, zip code, gender, race/ethnicity, diagnosis, treatment information and dates, and results.

 

3.                        Why do you want this information?We will use this information to help us plan or conduct new research studies.

 

4.                        Who will be able to use this information?This information will be used by your treating physician and may also be given to other researchers working with your treating physician to plan new research studies.

 

5.                        Will my information be kept private?Yes, this information will be kept private.Your treating physician and those working with your treating physician, will be allowed to see or use it, as described above.The Food and Drug Administration, the Office for Human Research Protections, and the University of Mississippi Medical Centerís Institutional Review Board and Office of Compliance may also review the information.Your medical information and records, once disclosed, may be re-disclosed by any of the recipients identified above and may no longer be protected by the Privacy Standards of the Health Insurance Portability and Accountability Act (HIPAA), which is a federal regulation designed to protect medical information, including medical information and records created through research.

 

6.                        Do I have to sign this form?No, you do not have to sign this form.If you do not sign it we will not be able to use your protected health information, as described above, but it will not affect your care in any way.

 

7.                        What if I sign this form but then change my mind?You can change your mind at any time and withdraw this permission.To withdraw your permission you must notify us in writing, by contacting [insert UMC contact name, address, and telephone number].

 

8.                        How long will this permission last?This permission [has no expiration date] [will expire_______].

 

 

 

 

_____________________________________________________________

Name of Participant or Participantís Legally Authorized Representative

 

 

 

_____________________________________________________________

Signature of Participant or Participantís Legally Authorized Representative

 

 

 

_____________________________________________________________

Legally Authorized Representativeís Right to Act

 

 

 

_______________________

Date