HIPAA Forms

HIPAA Research Forms

Version
Date

 1.      

Authorization for Use and Disclosure of Health Information for Research  (Revised)

05/2008

1.1 

05/2008

2.

Combined Informed Consent/Authorization Template
All new and revised consent forms are required to be on this template as of January 1, 2008.  Consent forms received after January 1, 2008 on an outdated template will be returned and the application will not be processed until the correct consent forms are submitted.

10/2007

3.

Authorization to Contact You About Future Research Studies

4.

Application for IRB Waiver of HIPAA Privacy Authorization

02/2006

5.

Representations Form for Research Involving Only Decedents' Information

03/2004

6.

Representations Form for Reviews Preparatory to Research 

8.1  

Tracking Form for Disclosure of PHI from Research Records
For Disclosures as Part of the Research Process - Basic Form

10/2004

8.2  

Tracking Form for Disclosure of PHI from Research Records
For Multiple Disclosures about an Individual to the Same Person or Entity for Single Purpose as Part of the Research Process

10/2004

Tracking Form - Research Involving Disclosures About 50 or More Individuals

10/2004

 Tracking Form for Permitted General Disclosures of PHI from Clinical or Research Records   

01/2007

9. 

Data Use Agreement

03/2003

10.

03/2004

Confidentiality Agreement for Workforce Members-General

Confidentiality Agreement for Professional Staff and other Credentialed Practitioners - Howard County General Hospital