HIPAA Authorization

AUTHORIZATION FOR USE AND DISCLOSURE

OF PROTECTED HEALTH INFORMATION

HIPAA Authorization | 45 C.F.R. Section 164.508

This Authorization permits the use and disclosure of your protected health information ("PHI") as described below. Completing this Authorization is voluntary.

Patient name: ____________________ Date of birth: ____________________

2. Information to Be Used or Disclosed

This Authorization applies to the following PHI: [describe the specific information, for example, treatment records, outcomes data, laboratory results, and images relating to the protocol or condition specified]. [Specify the categories with particularity; a general description is not sufficient under 45 C.F.R. Section 164.508.]

3. Persons Authorized to Make the Use or Disclosure

The treating physician, practice, or clinic that holds your records, as identified on the signature page of this Authorization.

4. Persons or Class Authorized to Receive the Information

MedGrid, LLC, and [as applicable, the manufacturers, payers, or research institutions to which de-identified outcomes data may be licensed]. MedGrid, LLC and its ClinicalX outcomes platform, for inclusion in de-identified research datasets.

5. Purpose

The purpose of this use and disclosure is [for example, to contribute the information to the ClinicalX outcomes database and to support research, protocol development, and, in de-identified form, data licensing]. You acknowledge that, once de-identified in accordance with 45 C.F.R. Section 164.514(b), information is no longer PHI and is not subject to this Authorization.

6. Expiration

This Authorization expires upon the conclusion of the ClinicalX research activity described above or upon your written revocation, whichever occurs first.

7. Your Rights

• Right to Revoke. You may revoke this Authorization at any time by written notice to the person identified in Section 3, except to the extent action has already been taken in reliance on it. Revocation will not apply to information already used or disclosed, or to de-identified information.
• No Conditioning. Your treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether you sign this Authorization, except as permitted by 45 C.F.R. Section 164.508(b)(4).
• Potential for Redisclosure. Information disclosed under this Authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA, although it may be protected by other law. De-identified information is not individually identifiable.
• Copy. You are entitled to a copy of this signed Authorization.

Signature of patient or personal representative: ____________________ Date: __________

If signed by a personal representative, description of authority: ____________________