HIPAA Privacy Authorization Form
For questions and help, please contact:
Leigh Pruneau, PhD, RN, CIP., Human Research Protection Program Administrator
2200 Webster Street, 5th Floor, Pacific Campus,
San Francisco, CA 94115
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- HIPAA Privacy Authorization Form - English [PDF]
- HIPAA Privacy Authorization Form - Chinese Simplified [PDF]
- HIPAA Privacy Authorization Form - Chinese Traditional [PDF]
- HIPAA Privacy Authorization Form - Korean [PDF]
- HIPAA Privacy Authorization Form - Russian [PDF]
- HIPAA Privacy Authorization Form - Spanish [PDF]
- HIPAA Privacy Authorization Form - Vietnamese [PDF]
HIPAA Privacy Authorization Form Text:
- Principal Investigator:
- Address of Principal Investigator:
- Authorization Expiration Date:
Your authorization is required for participation in the research study.
You may revoke your authorization at any time by sending a written notification to your study doctor at the address above. We will discontinue collecting, using or disclosing your information except as required to maintain the integrity of the research study or as required by law. However, a revocation will not be effective for information that the study doctor has already used or disclosed while the authorization was in effect. For example, we may need to use your information to document why you have withdrawn from the study, for compliance reporting purposes, or to report adverse events.
During the research study, your research team will look at the following information:
- Billing records for healthcare services
- Medical records
- Lab, pathology and/or radiology results
- Mental Health records
- Previous Research records
- Questionnaires and interviews
- Other (specify):
During the research study, your research team may disclose your PHI to the following individuals or organizations:
- California Pacific Medical Center Institutional Review Board for oversight purposes
- Study sponsor:
- Contract research organization (CRO):
- Office for Human Research Protections (OHRP); Food and Drug Administration (FDA); or National Institutes of Health (NIH) for safety, efficacy, and compliance reports. Also included are other federal or state agencies that have authority over the research project or other governmental offices as required by law.
- Statistician for data analysis
- Outside lab for specimen processing
- A data safety monitoring board, if applicable
- Others (list all that apply):
RESEARCH SUBJECT’S STATEMENT
I hereby authorize the Principal Investigator listed above and the research team to use and disclose my protected health information as described above for research purposes.
If conservator or individual authorized to make health decisions on behalf of the Research Subject, state relationship to Research Subject:
- Please initialed (provide research subject’s initials) if you authorize the Principal Investigator named above to obtain copies of any of my medical records needed for purposes of the research while I am enrolled in this study.
- Please initialed (provide research subject’s initials) if you acknowledge that my right to access my health information pertaining to the research study will be suspended until the study is concluded.