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	4/2012
2.		Combined Informed Consent/Authorization Template	03/2012
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	01/2007
9.		Data Use Agreement	12/10/09
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
	12.1	Authorization for Use of Research Information and Photographs