For research involving IIHI where subject authorization is sought 研究涉及的主题iihi授权要求

Confidentiality of Records and Authorization to Use/Share Protected Health Information for ResearchI

ConfidentialityofRecordsandAuthorizationtoUse/ShareProtectedHealth InformationforResearch identifiablehealthinformationabout Ifyouagreetoparticipateinthisresearch, youwill beusedandsharedwithothersinvolvedinthisresearch.Foryouto beinthisresearchweneedyourpermissiontocollectandsharethis Federallawprotectsyourrighttoprivacyconcerningthisinformation. information. Whenyousignthisconsentformattheend,itmeansthatyouhavereadthissectionand authorizetheuseand/orsharingofyourprotectedhealthinformationasexplainedbelow. YoursignaturealsomeansyouhavereceivedacopyofUpstate’sNoticeofPrivacy TheNoticeofPrivacyPracticesshouldbegiventoeachsubjectatthetime Practices. . consentforparticipationinthestudyisobtained Individuallyidentifiablehealthinformationunderthefederalprivacylawisconsideredto beanyinformationfromyourmedicalrecord,orobtainedfromthisstudy,thatcanbe associatedwithyou,andrelatestoyourpast,present,orfuturephysicalormentalhealth orcondition.Thisisreferredtoasprotectedhealthinformation. Yourprotectedhealthinformationwillbekeptconfidential.Youridentitywillnotbe revealedinanypublicationorpresentationoftheresultsofthisresearch. Forresearchactivities,whereacertificateofconfidentiality(COC)hasbeenobtained, inserttheCOClanguagehere. Ifthestudyinvolvestheuseofphotography/video/audiotapingofthesubject,includea statementspecificallyaddressingforwhatpurposesthephotos/tapeswillbeused, whohasaccesstothethem,howtheyarestored,andwhathappenstothemoncethe studyisended(i.e.,Aretheydestroyed/erasedafterallthenecessaryinformationis collectedfromthem?Aretheykeptforarchivalpurposes,educationalpurposes?). Whyisitnecessarytouse/shareyourprotectedhealthinformationwith others? Themainreasontouseandshareyourhealthinformationistoconduct theresearchasdescribedinthisconsentform.Yourinformationmayalso besharedwithpeopleandorganizationsthatmakesuretheresearchis beingdonecorrectly,andtoreportunexpectedorbadsideeffectsyou mayhave. Inaddition,wemayberequiredbylawtoreleaseprotectedhealthinformationaboutyou; forexample,ifajudgerequiressuchreleaseinalawsuit,orifyoutellusofyourintentto harmyourselforothers. Whatprotectedhealthinformationaboutyouwillbeusedorsharedwithothersas partofthisresearch?