4—Appendix D: Authorization to Disclose Protected Health Information for Research Databases and Repositories Outside of [Covered Entity]

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.”

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