Healthcare Project Approval

HEALTHCARE PROJECT APPROVAL

Project Title:    Project ID:

Department:    Project Lead:

Role:    Contact (email/phone):

Project Details

Projected Start Date:    Projected End Date:

Regulatory & Compliance Review

HIPAA/privacy review required    Institutional Review Board (IRB) review required

Infection control review required    Data security assessment required

Patient Information (if applicable)

Date of Birth:    Gender:

Insurance Information

Medical History (relevant to project)

Data Use Authorization & Patient Consent

I understand that participation and use of my data for this project is voluntary and that I may withdraw my authorization at any time by providing written notice to the project lead. I acknowledge my right to withdraw.

Authorization Expiration Date:

I have received and reviewed the privacy practices that describe how my protected health information may be used and disclosed for this project.

I acknowledge that data will be stored and retained according to organizational policy and applicable law, and that safeguards will be implemented to protect confidentiality.

Certification by Patient / Authorized Representative

By signing below I certify under penalty of perjury that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize the described use of my health information and/or my participation in the project identified above. I understand the purposes for which my information will be used, the parties who may receive my information, and the procedures through which I may revoke this authorization in writing. I understand that revocation will not affect disclosures already made in reliance on this authorization prior to receipt of my written revocation.

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