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HIPAA Forms

 

Title

Version
Date

 1.      

Authorization for Use and Disclosure of Health Information for Research  

06/2010

          

1.1 

HIPAA Authorization for International Research  

01/2014

2.

Combined Informed Consent/Authorization Template

10/2013

3.

Authorization to Contact You About Future Research Studies 

01/2013

4.

Application for IRB Waiver of HIPAA Privacy Authorization 

06/2010

5.

Representations Form for Research Involving Only Decedents' Information

06/2010

8.  

Tracking Forms for Research Associated Disclosures

        

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

     

8.3  

Tracking Form - Research Involving Disclosures About 50 or More Individuals

10/2004

     

8.4  

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

12/1/2012

9. 

Data Use Agreement 

12/1/2013

10.

Use or Disclosure of Psychotherapy Notes for Research

03/2004

 

10.1

Authorization for Use or Disclosure of Psychotherapy Notes for Research (and instructions)

03/2004

11.

Confidentiality Agreements

 

11.1

Confidentiality Agreement for Medical Staff, Resident Staff and Other Credentialed Staff Members

 

 

11.2

Confidentiality Agreement for Workforce Members-General

 

 

11.3

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

 
12. Authorizations 
 12.1Authorization for Use of Research Information and Photographs 



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