Healthcare Life Science Update

HEALTHCARE LIFE SCIENCE UPDATE

Use this form to report changes to personal, medical, insurance, specimen, and research data preferences. Completion of this Healthcare Life Science Update updates records used for clinical care and for authorized life science or research activities. Provide complete and accurate information to ensure continuity of care and correct handling of biological specimens and health data.

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History Update

Have there been any changes since your last record? Please check all that apply:

No known allergies

New diagnosis since last update:

Pregnancy status (if applicable): Currently pregnant Planning pregnancy Not applicable / None

Life Science / Research Specimen and Data Preferences

The following options govern the retention, research use, and sharing of biological specimens and health data that may be collected in clinical care or life science activities. Select your preferences below. Consent may be revoked at any time in writing; revocation will not affect uses already completed prior to receipt of revocation.

I authorize storage of leftover biological specimens for future life science research and development under applicable oversight and privacy protections.

Authorization expiration date (if applicable):

I consent to use of my de-identified health data for research, quality improvement, and method development.

I consent to genomic or genetic analysis of specimens when clinically or scientifically indicated and to inclusion of results in my record where required by clinical care or reporting obligations.

I consent to sharing specimens or data with third-party collaborators, including commercial partners, subject to contractual protections; identifiable information will not be shared without separate authorization.

I agree to be re-contacted about future studies or follow-up related to life science research. Preferred re-contact method:

Privacy, Data Use, and Acknowledgments

I acknowledge that medical records and information derived from specimens may be used for authorized research and quality improvement, under safeguards to protect privacy. Identifiable data will only be used or disclosed as permitted by law and any separate authorization I provide. I understand that research results may not be clinically validated and may not be returned unless required by policy or clinical necessity.

I understand that I may revoke any of the consents checked above at any time by delivering a written revocation to the designated records office. Revocation will not affect uses or disclosures made prior to receipt of revocation.

Acknowledgment of Privacy Notice: I acknowledge I have received or had the opportunity to review the privacy practices and notice regarding the use and disclosure of health information for clinical and research purposes.

Updates Summary

By signing below I certify that the information provided is true and complete to the best of my knowledge. I authorize the release and use of my health information and specimens as indicated above for clinical care and for the life science activities and research uses I have consented to. I understand the rights and limitations described herein.

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