Healthcare Tissue Document

HEALTHCARE TISSUE DOCUMENT

Patient Identification

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Tissue / Specimen Details

Facility / Collector Name:

Collection Date:    Specimen ID:

Blood    Tumor    Bone    Cartilage    Organ    Other

Purpose and Use

Intended Use (check all that apply): Treatment / Transplantation Diagnostic Testing Research Education / Training Quality Improvement Commercial Development

If research or commercial development is selected, I understand that tissue or data derived from this tissue may be de-identified and used for current or future research projects, method development, diagnostic assay validation, or transferred to third parties including commercial entities. I further understand that such uses may result in intellectual property or commercial products from which I will not receive financial benefit unless a separate agreement is executed.

Authorization and Consent

By signing below I authorize the collection, retention, analysis, storage, and lawful disclosure of the tissue described above for the purposes indicated. This authorization includes release of associated medical information necessary to accomplish the purposes stated, including pathology reports, clinical history, and diagnostic test results. I authorize the transfer of tissue or derivatives to other institutions, repositories, or commercial entities for the stated purposes.

Expiration: This authorization will remain in effect until unless earlier revoked in writing. If no date is provided, the authorization will remain effective for uses consistent with applicable law and institutional policy.

Risks, Benefits, and Alternatives

I understand there may be minimal physical risks associated with collection or processing of tissue, including but not limited to infection, bleeding, scarring, or additional diagnostic procedures. There may be no direct medical benefit to me when tissue is used for research or commercial development. Alternatives to donation include refusing authorization or limiting the scope or duration of this authorization.

Compensation and Costs

I understand that I will not receive compensation from the facility, researchers, or third parties for the donated tissue, nor will I be charged by the facility for the research use of the tissue except for routine clinical charges associated with collection when applicable. Any payment for services or commercial products derived from research on this tissue will not be distributed to me unless a separate written agreement exists.

Privacy and HIPAA Authorization

I authorize the use and disclosure of my protected health information (PHI) as reasonably necessary to accomplish the permitted uses described above. I understand that PHI disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws to the same extent.

I authorize (check to agree): Use and disclosure of PHI as described in this document.

Genetic Testing and Incidental Findings

Tissue may be subject to genetic or genomic testing. Such testing may reveal information about inherited traits or conditions. I understand that results may have implications for family members. I choose to be informed of clinically significant incidental findings: Yes No

Revocation and Questions

I understand I may revoke this authorization at any time by providing a written notice to the facility named below. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation. To request revocation or for questions about this authorization contact:

Certification

By signing this document I certify that I am the patient named herein or that I have the legal authority to act on behalf of the patient. I acknowledge that I have read and understand the information above, that my questions (if any) have been answered to my satisfaction, and that I voluntarily authorize the collection and use of tissue as described.

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