Name and credentials AND mailing address!

enter email address of PI or knowledgeable designee

(the following person(s), class(es) of persons, and/or organization(s) who may disclose, use , and receive the information, but they may only use and disclose the information to the other parties on this list, to the research subject or his/her personal representative, or as otherwise permitted or required by law:

▪    The Principal Investigator and the research staff and any other people and groups authorized to help conduct the study.

▪    The study sponsor for this research study. The sponsor may also use your PHI to collect and analyze the results of the research and may have other people and groups help conduct, oversee, and analyze the study. These people will use your PHI.

▪    Every health care provider who provides services to you in connection with this study.

▪    Anyone who has access to your medical records.

▪    Any laboratories and other individuals and organizations that analyze your health information in connection with this study in accordance with the study’s protocol.

▪    The Institutional Review Board and the Office of Research Services.

▪    Any government agencies that regulate research including: the Office for Human Research Protections, The Food and Drug Administration, Medicare, Medicaid, and other regulatory agencies.

▪    Data and Safety Monitoring Boards / Ethics Committees, research monitors and reviewers.

▪    Others, specify:

You do not have to sign this authorization form. If you do not sign, you may not participate in the above-mentioned research study. Piedmont providers shall not condition treatment on the receipt of this authorization and you may still get non-research related treatment. You may even sign and at any later time revoke this Authorization. If you do wish to revoke authorization you must write to the mailing address included above in this document.    

After that point, the researchers would not collect any more of your PHI. But they may use or pass along the information you already gave them so they can follow the law, protect your safety, or make sure the research was done properly. The information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of the information and may then no longer be protected by the federal privacy regulations. This authorization for use and disclosure for research purposes indicated above is valid until the research study ends or you revoke it. You will be given a copy of this authorization.

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