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4—Appendix C: Sample Research HIPAA Authorization Form

PROTOCOL TITLE: _______________________________________________

PROTOCOL NUMBER: _______________________________________________

PRINCIPAL INVESTIGATOR: _______________________________________________

The word “you” means both the person who takes part in the research and the person who gives permission to be in the research. This form and the attached research informed consent form need to be kept together. The words “we” and “[CE]” mean the [Covered Entity].

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