Disclosure Authorization

| Authorization (Permission) to Use or Disclose (Release) Protected Health Information (PHI) for Research |

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Study Title: | |

Principal Investigator: | |

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1. What is the purpose of this form?

This form is required by the Health Insurance Portability and Accountability Act of 1996. Specifically the privacy regulation (HIPAA) permits the research investigators listed above to use and disclose health information about you for the research study identified above which has been approved by the Solutions Institutional Review Board.

Researchers would like to use your protected health information for research. The elements of protected health information as defined by HIPAA are:

Data Elements for Protected Health Information (PHI)

* Names

* All geographic subdivisions smaller than a state (except for the first 3 digits of the zip code in some cases)

* All elements of dates (except year) for dates directly related to an individual (e.g., birth date, admission date, discharge date, date of death) and all ages over age 89 and dates indicative of that age

* Telephone numbers

* Fax numbers

* E-mail addresses

* Social security numbers

* Medical record numbers

* Health plan beneficiary numbers

* Account numbers

* Certificate/license numbers

* Vehicle identifiers and serial numbers, including license plate numbers

* Device identifiers and serial numbers

* Web Universal Resource Locators (URL)

* Internet Protocol (IP) addresses

* Biometric identifiers, including finger and voice prints

* Full face photos and any comparable images

* Any other unique identifying number, characteristic, or code

2. What protected health information do the researchers want to use?

REVISE LIST BELOW TO REFLECT ONLY THOSE HIPAA ELEMENTS YOU WILL USE.

The researchers want to copy and use the portions of your medical record that they will need for their research. If you enter a research...