Market Research Participant HIPAA Authorization Form for Use or Disclosure of Protected Health Information (PHI) (In accordance with HIPAA Act 45 CFR 160 and 164) 

Market research study title: Patient Interest in Gene Therapy Hemophilia A         

 

PHI disclosure purpose:
By signing this form you give us permission to use or disclose your requested PHI (itemized below) for the conduct, operation and oversight of the above-mentioned market research study for gene therapy currently in clinical trials.

 

PHI that will be Used or Disclosed:

Medical information collected in the market research study

Data created during the market research study

 

People that will Use or Disclose your PHI:

(the following person(s), class(es) of persons, and/or organization(s) who may disclose, use , and receive the information, but they may only use and disclose the information to the other parties on this list, to the market research subject or his/her personal representative, or as otherwise permitted or required by law.

• Clinical trial research personnel, and any other people and groups authorized to help conduct the market research study.
• Clinical trial research personnel will also use your PHI to collect and analyze the results of the market research and may have other people and groups help conduct, oversee, and analyze the study data to make decisions in the clinical direction and commercialization.
• Any affiliate of clinical researchers who provide services to patients in connection with this study.
• The Institutional Review Board.

 

 

Revoking your Authorization:
You do not have to sign this authorization form. If you do not sign, you may not participate in the above-mentioned market research study. You may even sign and at any later time revoke this Authorization. If you do wish to revoke authorization you must email and request revocation of your HIPAA Authorization. After that point, the market researchers would not collect any more of your PHI. But they may use or pass along the information you have already provided so they can follow the law, protect your safety, or make sure the market research was done properly. The information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of the information and may then no longer be protected by the federal privacy regulations. This authorization for use and disclosure for market research purposes indicated above is valid for three years from the date of this authorization. Checking the Authorization box below, entering your name and submitting this form constitutes your signature and agreement to this Authorization.