Sample Form: Authorization Form for Disclosure of Health Information for Research Purposes

I voluntarily give permission for the use or disclosure of my health information as stated below for the research study titled, (Research title).

 The following people may provide my health information:

The following people may receive my health information:

This information is being disclosed for the following purposes: (Include study title) 

I may withdraw my permission at any time by writing to (insert PI name and address). If I withdraw my permission, any information already disclosed cannot be taken back. Once information about me is disclosed as this form states, the person receiving the information may disclose the information and it may no longer be protected by federal privacy laws.

I may refuse to sign this form. If I choose not to sign this form, I may not be able to participate in this research study. My decision not to sign this form will not affect my relationship with my doctors, hospital, or insurance.

This permission will expire when the research ends (give a date or state "the authorization will have no expiration date").

If I have any questions about this form or the research, I can call (PI name and phone number and second contact and phone number) or the Office of Research and Program Development at the University of North Dakota at (701) 777-4279.
I will be given a signed copy of this form.

 Signature and date line for subject or subject's legal representative

 Printed name of subject or legal representative