4—Appendix F: Sample Tracking Form for Accountings of Research Disclosures (Fewer than 50 Individuals)

Instructions: Use this form to track disclosures to an individual or entity outside of [Covered Entity] of protected health information (PHI) for purposes of research where individual participant HIPAA authorization is not obtained. For example, this form must be used when PHI is disclosed:

  • Preparatory to research

  • Pursuant to an Institutional Review Board waiver of HIPAA authorization

This document is only available to subscribers. Please log in or purchase access.