Franklin Pierce University

HIPAA Authorization Form

Authorization to Use Personal Health Information that Identifies You for a Research Study

If you sign this document, you give permission to the researchers at Franklin Pierce University to use or disclose health information that identifies you for their research study: [INSERT TITLE AND DESCRIPTION OF RESEARCH STUDY].

What information may be used by the researchers of this study?

The health information that may be used includes your personal and medical information. For example:

Past and present medical records

[LIST ANY OTHER INFORMATION]

Who will use or receive my health information?

The health information listed above will be accessible only to the study researchers and the FPU IRB.

Why will this information be used?

To gather data to do the research, to study the results, and to make sure that the research was done right.

Is my health information protected after it has been given to the researchers of this study?

Researchers are required to keep your information private. Any public or published information will not identify you.

What if I decide not to give permission to use my health information?

You do not have to sign this document, but if you do not, you will not be able to participate in this study. If you do not sign this document, your right to other medical treatment will not be affected.

May I withdraw or revoke (cancel) my permission?

You may change your mind and withdraw your permission at any time. When you withdraw your permission, no new health information identifying you will be gathered after that date. Information that has already been gathered may still be used. To withdraw your permission, you must write to: [INSERT RESEARCHER NAME AND CONTACT INFORMATION].

Does my permission have an expiration date?

This permission does not have an expiration date. [OR INSERT EXPIRATION DATE/STUDY END].

Authorization Agreement

I have read the information in this authorization form and agree to allow my health information to be used as described above.

_________________________ Signature of participant or participant's personal representative	_________________________ Date
_________________________ Printed name of participant or participant's personal representative	_________________________ If applicable, a description of the personal representative's authority to sign for the participant