HIPAA Authorization for Use and Disclosure of Health Information
Purpose. You are being asked to authorize the use and disclosure of your health information for the purpose of determining your eligibility for, and participation in, a clinical research study conducted by Clinical Research Philadelphia (CRP).
What information will be used or disclosed? The following information may be used and disclosed as part of this research: medical history and physical exams; laboratory results and test reports; medications and treatment history; information from other health care providers or medical records; any information collected during the course of the study.
Who will receive and use my information? Your health information may be disclosed to: Clinical Research Philadelphia (CRP) staff; the study sponsor and its representatives; regulatory agencies such as the FDA, Office for Human Research Protections (OHRP), and the Institutional Review Board (IRB); third-party laboratories or vendors involved in the study (e.g., Pluto Health).
Why is my information being used? Your information is being used to: determine your eligibility to participate in the study; conduct and monitor the study; comply with legal and regulatory requirements.
Is my health information protected after it’s disclosed? Once your health information is disclosed to others who are not required to follow HIPAA (such as the study sponsor), it may no longer be protected under federal privacy laws. However, efforts will be made to protect your confidentiality in accordance with applicable laws and research policies.
How long will this authorization last? This authorization does not expire unless you cancel it. It will remain in effect for the duration of the research and any required data retention period as specified by applicable regulations (which may be up to 15 years).
Can I cancel this authorization? Yes. You may revoke (cancel) this authorization at any time by submitting your request in writing to: Clinical Research Philadelphia (CRP), 9501 Roosevelt Blvd, Suite 208, Philadelphia, PA 19114 · info@phillyresearch.com · 215-676-6696. If you revoke your authorization, you will no longer be allowed to participate in the study. However, any information already collected may still be used if necessary to maintain the integrity of the research.
Do I have to sign this authorization? No. Signing this form is voluntary. However, if you choose not to sign it, you will not be allowed to participate in the research study.
