PROTOCOL TITLE: _______________________________________________
PROTOCOL NUMBER: _______________________________________________
PRINCIPAL INVESTIGATOR: _______________________________________________
This form and the attached informed consent form need to be kept together.
I authorize [Covered Entity] to disclose my protected health information (PHI) as more fully described below, for the purpose of including my PHI in a research database or repository that will be maintained outside of [Covered Entity] by the organization named below:
Name of organization: _______________________________________________
My PHI included in the research database or repository may be used for future research as described in the attached informed consent form. I understand that my PHI that is included in the research database or repository will identify me, and that when it is used for future research, it may or may not include information that identifies me. Information that does not identify me is called “de-identified information.”