HIPAA Authorization for Research Study Participation

Participant Name Date of Birth Research Study Title Study ID (if applicable)

Authorization to Use and Disclose Protected Health Information

I authorize the use and disclosure of my health information for participation in the research study described above. This authorization allows the following information to be used/disclosed:

If other, specify

Persons/Organizations Authorized to Receive Information Purpose of Use/Disclosure

Expiration

This authorization will expire on (date/event):

Signature

Signature of Participant or Legal Representative If Legal Representative, Relationship to Participant Date