Healthcare Study Samples

HEALTHCARE STUDY SAMPLES AUTHORIZATION

Patient Name:    Date of Birth:    Gender:

Patient Information

Study Details

Insurance & Medical History

Sample Collection Details

Sample Types to be collected (check all that apply):

Blood    Saliva    Tissue (biopsy)    Urine    Other:

Collection Date: Day   Month   Year

Authorization for Use of Samples and Health Information

By signing below, I authorize the collection, storage, testing and disclosure of biological samples and health information described above for the purposes of the study identified. I understand and agree that:

1. Samples and associated health information may be used for the current study and for future research related to biomedical or public health research, subject to the conditions set forth in this authorization.
2. I consent to the performance of analyses, including genetic testing, if indicated by the study. I acknowledge that genetic or genomic results may reveal information about me and my biological relatives.
3. I understand that my samples may be coded with a study identifier. The code linking the sample to my identity may be maintained by the study team; however, efforts will be made to de-identify samples when feasible.
4. I acknowledge that identified or coded information may be shared with collaborators, contractors, or laboratories for research, quality control, or commercial development. Such recipients may use the samples for research or product development.
5. I will not be entitled to financial compensation if discoveries, products, or commercial applications result from research on my samples.
6. Participation in this sample collection is voluntary and will not affect my right to receive medical treatment or insurance benefits. I may refuse or withdraw this authorization at any time as described below.

Specific consents (check yes or no):

Genetic testing: Yes No    Commercial use of samples: Yes No

Storage duration: Indefinite    Store for years

Privacy, Risks, and Benefits

Risks: Collection of samples may involve minor risks including pain, bruising, bleeding, infection, or discomfort. Genetic testing may reveal sensitive information. There is a risk of loss of privacy although safeguards will be used to protect identifiable information.

Benefits: There may be no direct benefit to me. The study may contribute to scientific knowledge, improved diagnostics, or treatments.

Confidentiality: My health information and samples will be handled in accordance with applicable privacy protections. Identifiable information will be disclosed only as necessary to authorized study personnel, contractors, or review boards. Complete confidentiality cannot be guaranteed.

Right to Revoke

I may revoke this authorization at any time by delivering a written notice to the Principal Investigator or study contact listed above. Revocation will not affect uses or disclosures already made based on this authorization prior to receipt of the revocation. After revocation, no new collections or uses will occur, except as required to comply with regulatory obligations.

Authorization Expiration

This authorization will expire on: Day   Month   Year    Or upon completion of the study:

Acknowledgments

I acknowledge that: (a) I have had the opportunity to ask questions about the collection and use of my samples, (b) my questions have been answered to my satisfaction, and (c) I have received sufficient information about the study to make an informed decision.

I understand that I will not necessarily receive individual research results unless the study team determines that clinically actionable findings should be returned and procedures for return have been established.

I acknowledge receipt of the study privacy notice and understand how my information will be used.

Optional: Recontact and Return of Results

I consent to be recontacted for future research related to this study: Yes No

Certification and Signature

I certify that I am the patient named above or the patient's legally authorized representative and that I have read and understand this authorization. I authorize the collection and use of my samples and health information as described above.

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