Authorization to Use and Disclose Protected Health Information (HIPAA Language)

 When we use the term ”you” in this section, we are referring to you and/or your child. The federal privacy regulations of the Health Insurance Portability & Accountability Act (HIPAA) protect your identifiable health information. By signing this form, you are permitting the University of South Florida to use your health information for research purposes.

You are also allowing us to share your health information with individuals or organizations other than USF who are also involved in the research and listed below. In addition, the following groups of people may also be able to see your health information and may use that information to conduct this research:

• The staff who are part of this research study;
• The USF Institutional Review Board (IRB) their related staff who have oversight responsibilities for this study, including staff in USF Research Integrity and Compliance and the USF Health Office of Clinical Research;

• Data Safety Monitoring Boards or others who monitor the data and safety of the study;
• Department of Defense (DoD)

Anyone listed above may use consultants in this research study, and may share your information with them. If you have questions about who they are, you should ask the study team. Individuals who receive your health information for this research study may not be required by the HIPAA Privacy Rule to protect it and may share your information with others without your permission. They can only do so if permitted by law. If your information is shared, it may no longer be protected by the HIPAA Privacy Rule. By signing this form, you are giving your permission to use and/or share your health information as described in this document. As part of this research, USF may collect, use, and share the following information:

• This pre-screening questionnaire

You can refuse to sign this form. If you do not sign this form you will not be able to take part in this research study. However, your care outside of this study and benefits will not change. Your authorization to use your health information will not expire unless you revoke (withdraw) it in writing. You can revoke your authorization at any time by sending a letter clearly stating that you wish to withdraw your authorization to use your health information in the research. If you revoke your permission:

• You will no longer be a subject in this research study;
• We will stop collecting new information about you;
• We will use the information collected prior to the revocation of your authorization.This information may already have been used or shared with others, or we may need it to complete and protect the validity of the research; and
• Staff may need to follow-up with you if there is a medical reason to do so.

To revoke your authorization, please write to:

Principal Investigator For IRB Study #4491

University of South Florida College of Nursing

12901 Bruce B Downs Boulevard, MDC 22 Tampa, FL 33612

While we are conducting the research study, we cannot let you see or copy the research information we have about you. After the research is completed, you have a right to see the information about you, as allowed by USF policies.

Consent to Participate and Parental Permission for My Child to Participate in this Research Study and Authorization to Collect, Use and Share Health Information for Research

I freely give my consent take part and to let my child take part in this study and authorize that his/her and/or my health information as agreed above, be collected/disclosed in this study.