Authorization Forms

• HIPAA Form 1 - Authorization for Use and Disclosure of Health Information for Research
  • Spanish Version - Authorization for Use and Disclosure of Health Information for Research
• HIPAA Statement for International Research Form
• HIPAA Form 3 (Adult) - Authorization to Contact You About Future Research Studies: Adult
• HIPAA Form 3 (Child) - Authorization to Contact You About Future Research Studies: Child
• HIPAA Form 4 - Application for IRB Waiver of HIPAA Privacy Authorization
• HIPAA Form 5 - Representations Form for Research Involving Only Decedents' Information

Tracking Forms for Research Associated Disclosures

• HIPAA form 8.1 - Tracking Form for Disclosure of PHI from Research Records
  For Disclosures as Part of the Research Process - Basic Form
• HIPAA Form 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
• HIPAA form 8.4 - Tracking Form for Permitted General Disclosures of PHI from Clinical or Research Records
• HIPAA Form 10.1 - Authorization for Use or Disclosure of Psychotherapy Notes for Research (and instructions)
  • Organizational Policy on the Use or Disclosure of Psychotherapy Notes for Research
• If you require a Data Use Agreement please contact ORA  or JHURA [email protected]

Confidentiality Agreements

• Form A.3.1.a. - Confidentiality Agreement for Workforce Members-General
• Form A.3.4.a - Confidentiality Agreement for Medical Staff, Resident Staff and Other Credentialed Staff Members

Authorizations

• Form A.2.2.c. - Authorization for Use of Research Information and Photographs