Complete the bracketed areas of both forms. Place a copy of this form into the patient鈥檚 chart and send a copy to [insert appropriate Hospital/Health System Representative].
The forms will work if there is a patient or authorized representative who can give authorization. If patient is not able to sign, a request could be sent to the HIPAA Privacy Board for waiver of authorization.
HIPAA Authorization Form - Medical Case Report
[insert Hospital/Health System Name]
Case Report: [insert case report title]
Principal Author: [insert name and credentials, institutional affiliation, contact phone number]
Medical Student Author (if different from Principal Author): [insert name]
Please read this form carefully and take your time to make your decision and ask any questions that you may have.
You are being asked to consider allowing Dr. [insert name] of [insert Hospital/Health System Name] and Osteopathic Medical Student [insert name] of the 91原创 Heritage College of Osteopathic Medicine to use information about your [insert condition/disease/experience] to write what is called a case report. Case reports are typically used to share new unique information experienced by one patient during their clinical care that may be useful for other physicians and members of a health care team. A case report may be published in a medical journal in print and on the internet for others to read, and/or presented at a medical conference. Readers include not only physicians, but also journalists and other members of the public. This form explains the purpose of this case report.
The purpose of this case report is to inform other physicians that [insert specific reason (i.e., patients presenting to the ER with X may be related to Y, however, was masked by a common over the counter medication Z)]. We believe that the material has educational or scientific value that may help to improve the care that other patients receive in the future.
Your information being used for this case report includes [insert specific information].
We are obligated to protect your privacy and not disclose your personal information (information about you and your health that identifies you as an individual e.g., name, date of birth, medical record number). When the case report is published or presented, your identity will not be disclosed. However, the report may information such as your age, gender, and ethnic origin.
Although your personal information collected or obtained will be kept confidential and protected in accordance with the law, there is a limited risk associated with this case report that could result in a loss of confidentiality such as if your condition is rare and you have shared your medical information with others.
You will not directly benefit from allowing your information to be used in this case report. You will not receive any compensation. Allowing your information to be used in this case report will not involve any additional costs to you.
Allowing your information to be used in this case report is your choice (voluntary). You will receive the same care even if decide not to allow your information to be used. You may choose not to allow your information to be used for this case report or you may change your mind at any time. Unless revoked, this authorization will be valid for 365 days from the date of signing. You may revoke your authorization by sending notice in writing to: [insert name, department, address]. However, once the case report is written and published, it will not be possible for you to withdraw your authorization. Your decision will not result in any penalty or loss of benefits to which you are entitled including the quality of care you receive.
You may be informed about any new information relating to this case report that may affect you.
Your signature below means that you have read the above information about this case report and have had a chance to ask questions to help you understand how your information will be used and that you give permission to allow your information to be used in this case report.
If you have any questions now or later, please contact [insert name] at [insert phone number].
Authorization Form - Medical Case Report
[insert Hospital/Health System Name]
Case Report: [insert case report title]
Principal Author: [insert name and credentials, institutional affiliation, contact phone number]
Medical Student Author (if different from Principal Author): [insert name]
Patient Name: [insert patient name]
Patient/Legally Authorized Representative
By signing this form, I confirm that:
Name of Patient/Legally Authorized Representative (print): [insert printed name]
Signature: [insert patient/representative signature]
Date: [insert date]
Time:[insert time] AM PM [circle one]
I have carefully explained to the patient the nature of the above case report. I certify that to the best of my knowledge the person who is signing this authorization form understands clearly that their information will be used in the above case report and their signature is legally valid. A medical condition or language or educational barrier has not precluded this understanding.
Name of Person Obtaining Authorization (print): [insert printed name]
Signature: [insert signature]
Date: [insert date]
Time:[insert time] AM PM [circle one]