AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION FOR RESEARCH PURPOSES
Information About the Research Study
Dr. Khamis Abu-Hasaballah and his staff are establishing a research registry called the University of Connecticut Study and Recruitment Registry (UCONN STARR). The purpose of the registry is to create a database of potential volunteers for research studies at the University of Connecticut (Farmington and Storrs campuses). The information in the registry will be used to contact you about participating in these studies. If you are contacted and decide to participate in a specific research study, you will be asked to sign a separate HIPAA Authorization at that time.
Because of a federal law called the Health Insurance Portability & Accountability Act (HIPAA), we must get your permission to use and disclose your identifiable health information for this research registry. This form is used to document that permission. Because of HIPAA you must also receive a copy of the Health Center’s rules about privacy.
Your decision whether to give permission is voluntary. The only consequence of not granting permission is that you will not be allowed to participate in this research registry.
Information That Will be Used / Disclosed
The following information about you may be used and disclosed for the purpose of this research: First Name, Last Name, Address, Phone (Day & Alternate), Email – restricted (not to be used by researchers to contact you), Gender, Date of Birth, Race, Ethnicity, Height, Weight, Information about your health and life style and interest in research studies.
How the Information Will be Used / Disclosed
The information noted above will be used and disclosed for the following purpose(s): to assess whether you are interested or possibly eligible to participate in research studies, and to contact you about potential participation in those studies.
People/Offices That Will Have Access to Your Information
The following people/entities may use and disclose your protected health information:
- Dr. Khamis Abu-Hasaballah and his staff
- The UCHC Institutional Review Board and Human Subjects Protection Office and Office of Research Compliance.
- The University of Connecticut’s (Storrs campus) Institutional Review Board and its representatives.
- Hospital or University of Connecticut Health Center representatives.
- Government representatives, such as the Office for Human Research Protections; when required by law.
- Other researchers at University of Connecticut, including the Farmington and Storrs campuses, who conduct studies for which you may be eligible for participation.
The researchers and staff agree to protect your information by using and disclosing it only as stated in this document and as directed by state and federal law.
Reasons to share your information are to be able to conduct research, and to ensure that the research meets legal, institutional and/or accreditation requirements.
Right to Access Information
You will not be allowed to review all of the information collected for this research registry. However, you will have access to your own information in the registry at any time while the registry/repository is active.
Expiration of Permission
Your permission to use and disclose your protected health information does not have an expiration date.
How to Withdraw Permission
You can withdraw your permission at any time by sending a letter to Dr. Khamis Abu-Hasaballah, UCONN STARR, 16 Munson Road, 3rd Floor, University of CT Health Center, Farmington, CT 06030-5340, to inform him. If you withdraw your permission you will no longer be allowed to participate in this registry. If you withdraw your permission the PI and his staff will no longer be able to use and disclose your protected heath information from this registry as it will be deleted from the research registry. There are exceptions to this. For example, the researchers may continue to use and disclose the protected health information that was collected for the registry prior to receiving the request to withdraw your permission.
Questions or Complaints
If you have any questions, concerns or complaints about your privacy rights, you may write to the Director of Patient Relations at the University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT 06030-1112. If you have a complaint, you may also write to the Federal Department of Health and Human Services (DHHS) at DHHS Regional Manager, Office of Civil Rights, U.S. Dept. of Health and Human Services Government Center, J.F. Kennedy Federal Building, Room 1875, Boston MA 02203. Complaints should be sent within 180 days of when you knew, or should have known, of the problem.
State of Connecticut Requirement
For this registry we are not asking for information about AIDS, HIV infection, behavioral health services, psychiatric care, or treatment for alcohol and/or drug abuse. If this type of information pertains to you, there is a slight chance that it may be inadvertently used or disclosed during the course of collecting information for this registry. The State of Connecticut requires that any release of this type of information be specifically authorized. By signing this dual-purpose authorization you acknowledge that there is a chance that such information may be used or disclosed.
Permission for Use and Disclosure of Information
You are a voluntary participant in this research registry, or you are authorized to act on behalf of the participant and are doing so voluntarily. By clicking the “I Agree” button below, you acknowledge that you have read this form, had the opportunity to ask questions, and obtain satisfactory explanations, and that you authorize the use and disclosure of protected health information as described in this form. Please print a copy of this form for your records.
The University of Connecticut Health Center’s Notice of Privacy Practice is provided to all patients and research participants. The Notice is available on-line at http://health.uchc.edu/privacy/index.htm. The Notice explains how your medical information may be used and disclosed and how you can get access to this information. Please review the Notice at this time on-line. If you have any questions about this Notice, please contact us at (860) 679-8141 or e-mail us at email@example.com.