ࡱ>  8bjbj 4}c}c0N: : 8 K28T"[q }1111111$4971![[!!1H2U&U&U&!R1U&!1U&U&r-T.+yM".120K2.z7"7..7. ^U&g L H11$K2!!!!7: G: SAINT LOUIS UNIVERSITY HIPAA Authorization Form Privacy Protection for ˻ֱ Volunteers Participant: IRB #:First Name / Last NamePrincipal Investigator (PI)Contact Phone #First Name / Last Name CredentialsTitle of Project:  INSTRUCTIONS: This template is to be used for researchers who are planning on conducting a research study that involves using, recording or sharing health information and identifiers. The combination of health information and identifiers is called protected health information or PHI. The Health Insurance Portability and Accountability Act (HIPAA) protects the use and disclosure of PHI. The instructions in this template are shaded or underlined so you can tell the difference between instructions and required language. Delete all shaded instruction boxes and underlined instructional text BEFORE submitting this form to the SLU IRB for review. To delete the instruction boxes, place your curser within the shaded box, right click the mouse, and select Delete Rows. To delete the underlined text, select the text by highlighting with your mouse, and push the delete button on your keyboard. In addition to the HIPAA authorization form, all subjects who accrue in research involving medical procedures or healthcare, regardless of payment arrangement, should be offered a paper copy of the HYPERLINK "/research/faculty-resources/research-integrity-safety/institutional-review-board-irb/irb_assets/slu_notice_of_privacy_practices.pdf"Notice of Privacy Practices (NPP). State and Federal privacy laws protect the use and release of your health information. Saint ˻ֱ University requires that private information about you be protected. This is especially true for your personal health information. Protected Health Information (PHI) is any health information that can identify you. To take part in this research study, you must give the research team permission to access your health information and to use and share your PHI. The research team will only use and/or share your information as described below and in the research consent form. What Health Information about me may be used or shared for this research study? INSTRUCTIONS: Mark each box that corresponds with the PHI to be used for your study. DOUBLE-CLICK ON CHECKBOXES IN ORDER TO MARK THEM. In the window that opens, change the default value to checked. This section should match the information provided in your IRB application. The last checkbox has been left blank to provide a description of an identifier not already listed (e.g., linkable codes). Add more specific information for Biometric identifiers, certificate or license numbers, photographic images, data from previous research studies (name source) or other if applicable. NOTE: The HIPAA Authorization allows the subjects permission for the use of PHI listed in this document ONLY. This authorization cannot be used for unspecified future research; a separate HIPAA Authorization or justification of a waiver of authorization is required for unspecified future uses of PHI. The PHI in this study will include:  FORMCHECKBOX Name FORMCHECKBOX Social Security Number FORMCHECKBOX Telephone Number FORMCHECKBOX Address FORMCHECKBOX Date of Birth FORMCHECKBOX  Fax Number FORMCHECKBOX Email Address FORMCHECKBOX Medical Record Number FORMCHECKBOX  Health Plan Beneficiary (Insurance) Number FORMCHECKBOX Account Number FORMCHECKBOX Certificate or License Number: FORMCHECKBOX  Vehicle identifiers and serial numbers FORMCHECKBOX Patient-Specific Dates (e.g., treatment dates) FORMCHECKBOX Biometric Identifiers (finger or voice prints) FORMCHECKBOX  Device Identifiers and serial numbers FORMCHECKBOX Web universe resource locators (URLs) or Internet Protocol (IP) addresses FORMCHECKBOX Photographic images, including: FORMCHECKBOX  Other: The PHI will be collected from the following sources:  FORMCHECKBOX  Hospital Medical Records FORMCHECKBOX  Physician or clinic records FORMCHECKBOX  Laboratory, pathology and/or radiology results  FORMCHECKBOX  Biological samples FORMCHECKBOX  Interviews or questionnaires/health histories FORMCHECKBOX  Data previously collected for research purposes obtained from:  FORMCHECKBOX  Other: Do I have to give my permission for certain information to be released? Delete the types of information that you do not need for your research. If none of the types of information are needed, this section may be removed completely. Yes. The following information will only be released as described in the research study consent form and below if you give your specific permission by putting your initials on the line(s). This is your specific permission for release of this information. ____I agree to the release of information pertaining to drug and alcohol abuse, diagnosis or treatment. Federal rules do not allow any use of the information to criminally investigate or prosecute any alcohol or drug abuse. ____I agree to the release of HIV/AIDS testing information. ____I agree to the release of information pertaining to sexually transmitted diseases. ____I agree to the release of information pertaining to mental health diagnosis or treatment. ____I agree to the release of genetic testing information. Who will my information be shared with? Your PHI will be maintained by Saint ˻ֱ University researchers [OR list appropriate party] and they will only share the information as described below. The researchers may use or share your health information with: The [central IRB name if applicable,] Saint ˻ֱ University Institutional Review Board and other University personnel in order to provide research oversight Federal or state government representatives, when required by law Physicians who have access to your medical record when required for your medical care [Hospital or representatives (if applicable)] in order to provide research oversight [List any collaborators, outside laboratories, sponsor, etc and for each listed, what PHI are shared and why.] [List any other groups with whom information may be shared, what is shared and why] [if applicable- statement that primary physician will be contacted if researcher in the course of the research learns of a medical condition that needs immediate attention] [INSERT THE FOLLOWING PARAGRAPH IF APPLICABLE.] The sponsor of this study is not covered by HIPAA. This means that the sponsor does not have to follow the same rules to protect your privacy. The researcher will send information to the sponsor. This information will contain PHI as listed above. In addition, the sponsor or its agents will review your research file and your medical record in order to verify data that are provided to them. Insert the following sentence below if it is applicable to the research study (e.g., PHI is provided to the sponsor that is not included on case report forms): As part of the accrual/screening/randomization process, the research team will provide the sponsor with information about you that is separate from the data collected during the course of the study. The researchers at Saint ˻ֱ University agree to protect your health information by using and/or disclosing it only as you authorize. However, if your PHI is shared with someone outside of the Saint ˻ֱ University research team and/or if you choose to share this information with others outside of this study, your health information may no longer be protected by HIPAA. Optional ˻ֱ Activity If your study contains optional research activities (i.e., participating in a biobank, the creation of a database, a tissue repository, etc.), or if you have specific future research plans that you would like to obtain HIPAA authorization for at this time, please complete and include the following section. Otherwise, delete. The researchers would like to ask your permission to use your PHI for the following optional research activities. You can choose whether or not to participate in these activities and it will not affect your ability to be in the main research study. Please initial on the line next to the optional activities to give your permission. ____I agree to allow my information to be disclosed for the please provide a description of the optional research study. This additional research is explained in detail in the consent form(s) and consent process that accompany this form. ____I agree to allow my information to be disclosed for the following future research activities: Adequately describe purposes such that it would be reasonable for the participant to expect that his or her PHI could be used or disclosed for such future research. Am I required to sign this document? Your decision to sign or not sign this form will not affect your standard medical treatment, payment or enrollment in any health plans or affect your eligibility for benefits. However, if you choose not to sign this form, you may not take part in this research study. Does my permission expire? This permission to release your PHI expires when the research study is over and all required study monitoring has ended. If you choose to sign this form: You can change your mind and not allow the researcher to use and/or share your PHI (revoke your authorization). If you revoke your authorization, you must send a written letter to: [insert PIs name and mailing address] to inform him/her of your decision. If you revoke your authorization, researchers may only use and/or share your PHI already collected for this research study. If you revoke your authorization, your PHI may still be used and/or shared should you have an adverse event (a bad effect). If you withdraw your authorization, you may not be allowed to continue in the study. If you have questions or concerns regarding your privacy and the use of your personal health information, please contact the University Privacy Officer at (314) 977-5545. [INSERT THE FOLLOWING STATEMENT IF THE STUDY INVOLVES MEDICAL PROCEDURES OR HEALTHCARE (REGARDLESS OF PAYMENT)] The Notice of Privacy Practices can be reviewed electronically at  HYPERLINK "https://www.slucare.edu/patient-information/legal-notices/notice-of-privacy-practices.php" https://www.slucare.edu/patient-information/legal-notices/notice-of-privacy-practices.php or if you prefer a paper copy, please request one at this time. By signing below you are acknowledging receipt of the Notice of Privacy Practices either electronically or as a hard copy. INSTRUCTIONS: Signature Lines in blue below are to be used when minors are involved in the research as participants. Delete the signature lines (in blue) that are not applicable to the study. As much as possible, the IRB stamp should appear on the same page as the participant signature line. __________________________________ Print Name of Participant __________________________________ ________________ Signature of ˻ֱ Participant (18 and over) Date - OR - __________________________________ Print Name of Participant __________________________________ Print Name of Parent/Guardian/Legal Representative __________________________________ ________________ Signature of Parent/Guardian/Legal Representative Date __________________________________ Description of Relationship to Participant SAINT LOUIS UNIVERSITY INSTITUTIONAL REVIEW BOARD APPROVAL STAMP This form is valid only if the IRBs approval stamp is shown below. __________________________________ Print Name of Principal Investigator or ˻ֱ Team Member __________________________________ ________________ Signature of Principal Investigator Date or ˻ֱ Team Member NOTE: The signature of the Principal Investigator or ˻ֱ Team Member that signs here must be authorized in the IRB-approved protocol to obtain informed consent and must sign at the SAME time as the above signatures are obtained. Failure to obtain HIPAA Authorization for the use and disclosure of PHI could result in the loss of research data.     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