Authorization Forms

1. Authorization for Use and Disclosure of Health Information for Research

• Spanish Version - Authorization for Use and Disclosure of Health Information for Research

1.1 HIPAA Statement for International Research Form

2. Authorization to Contact You About Future Research Studies: Adult
    Authorization to Contact You About Future Research Studies: Child

3. Application for IRB Waiver of HIPAA Privacy Authorization

4. Representations Form for Research Involving Only Decedents' Information

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

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

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

9. If you require a Data Use Agreement please contact ORA  or JHURA [email protected]

10. Use or Disclosure of Psychotherapy Notes for Research

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

Confidentiality Agreements

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

11.2 Confidentiality Agreement for Workforce Members-General

Authorizations

12.1 Authorization for Use of Research Information and Photographs