Authorization to use and disclose information

What information may be used and given to others?

The team will get your personal and medical information.  For example:

• Records.
• Records about phone calls made as part of this project/study.

Who may use and give out information about you?

Our team.

Who might get this information?

The sponsor of this study/project.  “Sponsor” means any persons or companies that are:

• Working for or with the sponsor, or
• Owned by the sponsor.

Your information may be given to:

• The U.S. Food and Drug Administration (FDA),
• Department of Health and Human Services (DHHS) agencies,
• Governmental agencies in other countries,
• The institution where this project/study is being done,
• Governmental agencies to whom certain diseases (reportable diseases) must be reported, and
• Institutional Review Board (IRB).

Why will this information be used and/or given to others?

• To do this project/research,
• To study the results, and
• To make sure that the project/study was done right.

If the results of this project/study are made public, information that identifies you will not be used.

What if I decide not to give permission to use and give out my health information?

Then you will not be able to be in this project/study.

May I review or copy my information?

Yes, but only after the project/study/research is over.

May I withdraw or revoke (cancel) my permission?

This permission will be good until December 31, 2070.

You may withdraw or take away your permission to use and disclose your health information at any time.  You do this by sending written notice to our team.  If you withdraw your permission, you will not be able to stay involved.

When you withdraw your permission, no new health information identifying you will be gathered after that date.  Information that has already been gathered may still be used and given to others.

Is my health information protected after it has been given to others?

There is a risk that your information will be given to others without your permission.

By selecting AGREE, I am confirming that I have been given the information about the use and disclosure of my health information for this project/study. My questions have been answered. I authorize the use and disclosure of my health information to the parties listed in the authorization section of this consent for the purposes described above.

By selecting DISAGREE, I am declining the use and disclosure of my health information.