Authorization to Use and Disclose Health Information. Institution and Principal Investigator shall provide an appropriate privacy notice to each Trial Subject and obtain a written privacy authorization from each Trial Subject, complying with Applicable Law, which will enable Institution and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor access to completed case report forms (“CRFs”), source documents and all other information required by the Protocol. If such an authorization is separate from the ICF, Institution and Principal Investigator will only use the authorization that is approved by Sponsor, IEC and/or RA (if applicable). 10.1.
Authorization to Use and Disclose Health Information. Institution and Principal Investigator will obtain a written privacy authorization, complying with all Applicable Law, for each Trial Subject which will enable Institution and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor with completed case report forms (“CRFs”), source documents and all other information required by the Protocol. Sponsor, though not a covered entity, recognizes that, pursuant to this Agreement, it has the responsibility to protect all individually identifiable patient information and to restrict the use of such information to those persons and entities, including consultants, contractors, subcontractors and agents, who must have access to such information in order to fulfill their assigned duties with respect to the Trial. Such use also will be restricted to those permitted in the authorization forms and neither Sponsor nor any party to whom Sponsor may disclose individually identifiable health information may use such information to recruit research subjects to additional studies, to advertise additional studies or products, or to perform marketing or marketing research. Institution and Principal Investigator will provide Sponsor or INC Research an opportunity to review and approve the content of the authorization (including any revisions made during the course of the Trial) before it is used. 10.1 P ovolenie použiť a zverejniť údaje o zdravotnom stave. Inštitúcia a Zodpovedný skúšajúci získajú pre každú Pokusnú osobu písomné formuláre povolenia využitia osobných údajov, ktoré budú v súlade so všetkými Príslušnými právnymi predpismi a ktoré umožnia Inštitúcii a Zodpovednému skúšajúcemu poskytovať Sponzorovi a ostatným osobám a subjektom, ktoré určí Sponzor, vyplnené formuláre správy o prípade („FSP”), zdrojovú dokumentáciu a všetky ostatné informácie vyžadované Protokolom. Sponzor, ktorý aj napriek tomu, že nie je povinným subjektom, uznáva, že podľa tejto Dohody má zodpovednosť za ochranu všetkých osobne identifikovateľných údajov o pacientoch a za obmedzenie použitia týchto údajov na tie osoby a subjekty (vrátane poradcov, dodávateľov, subdodávateľov a zástupcov), ktorí k nim musia mať prístup, aby mohli plniť svoje stanovené úlohy týkajúce sa Skúšania. Toto používanie sa obmedzí len na tie spôsoby, ktoré budú povolené vo formulároch povolení a ani Sponzor, ani žiadna strana, ktorej Sponzor môže poskytnúť individuálne identifikovateľné údaje o zdravotnom stave, nesmú využiť tieto údaje ...
Authorization to Use and Disclose Health Information. Institution and Principal Investigator will obtain a written privacy authorization, complying with Applicable Law, for each Trial Subject which will enable Institution and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor access to completed case report forms (“CRFs”), source documents and all other information required by the Protocol. Sponsor, though not a covered entity, recognizes that, pursuant to this Agreement, it has the responsibility to protect all individually identifiable patient information and to restrict the use of such information to those persons and entities, including consultants, contractors, subcontractors and agents, who must have access to such information in order to fulfill their assigned duties with respect to the Trial. Such use also will be restricted to those permitted in the authorization forms and neither Sponsor nor any party to whom Sponsor may disclose individually identifiable health information may use such information to recruit research subjects to additional studies, to advertise additional studies or products, or to perform marketing or marketing research. If such an authorization is separate from the ICF, Institution and Principal Investigator will only use such authorization that is approved by Sponsor, IEC (if applicable) and regulatory authority (if applicable). 11.
Authorization to Use and Disclose Health Information. Principal Investigator shall provide an appropriate privacy notice to each Trial Subject and obtain a written privacy authorization from each Trial Subject, complying with Applicable Law, which will enable Institution and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor access to completed case report forms (“CRFs”), source documents and all other information required by the Protocol. Principal Investigator will only use the authorization that is approved by Sponsorand acknowledged by EC. 10.1.
Authorization to Use and Disclose Health Information. Institution and Principal Investigator shall provide an appropriate privacy notice to each Trial Subject and obtain a written privacy authorization from each Trial Subject, complying with Applicable Law, which will enable Institution and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor access to completed case report forms (“CRFs”), source documents and all other information required by the Protocol. If such an authorization is separate from the ICF, Institution and Principal Investigator will only use the authorization that is approved by Sponsor, IEC and/or RA (if applicable). 10.2.
Authorization to Use and Disclose Health Information. Provider and Principal Investigator will obtain within an ICF a written privacy authorization, complying with all Applicable Law, for each Trial Subject which will enable Provider and Principal Investigator to provide Sponsor and other persons and entities designated by Sponsor with completed case report forms (“CRFs”), source documents and all other information required by the Protocol. Sponsor, though not a covered entity, recognizes that, pursuant to this Agreement, it has the responsibility to protect all individually identifiable patient information and to restrict the use of such information to those persons and entities, including consultants, contractors, subcontractors and agents, who must have access to such information in order to fulfill their assigned duties with respect to the Trial. Such use also will be restricted to those permitted in the authorization forms and neither Sponsor nor any party to whom Sponsor may disclose individually identifiable health information may use such information to recruit research subjects to additional studies, to advertise additional studies or products, or to perform marketing or marketing research. Provider and Principal Investigator will provide Sponsor or INC Research an opportunity to review and approve the content of the authorization (including any revisions made during the course of the Trial) before it is used. 11.
Authorization to Use and Disclose Health Information. I hereby authorize and direct Audiology Experts to release confidential medical information to any entity, government agency, or insurance carrier in order to secure payment related to services rendered. Audiology Experts may also disclose my health information to the referring physician, family doctor, and school personnel for transfer of medical care, and follow-up purposes. In addition to the above, my protected health information may be shared with the following: (e.g. spouse, child): Patient Signature (Guardian if patient is a minor) Date
Authorization to Use and Disclose Health Information. Institution will obtain a written privacy authorization, complying with Applicable Law, for each Trial Subject that will enable Institution to provide Sponsor and other persons and entities designated by Sponsor with completed Case Report Forms (“CRFs”), source documents and all other information required by the Protocol. Sponsor or INC Research, though not a covered entity, agrees to protect all individually identifiable patient information and to restrict the use of such information as described in the privacy authorization. Institution will provide Sponsor or INC Research an opportunity to review and approve the content of the privacy authorization (including any revisions made during the course of the Trial) before it is used. 9.1 Povolenie použiť a zverejniť údaje o zdravotnom stave. Inštitúcia získa pre každú Pokusnú osobu písomné formuláre povolenia využitia osobných údajov, ktoré budú v súlade s Príslušnými právnymi predpismi, a ktoré umožnia Inštitúcii poskytovať Sponzorovi a ostatným osobám a subjektom, ktoré určí Sponzor, vyplnené Formuláre správy o prípade („FSP”), zdrojovú dokumentáciu a všetky ostatné informácie vyžadované Protokolom. Sponzor alebo spoločnosť INC Research, ktoré aj napriek tomu, že nie sú povinným subjektom, sa zaväzujú chrániť všetky osobne identifikovateľné údaje o pacientoch a obmedziť použitie týchto údajov, ako to je opísané v povolení využitia osobných údajov. Inštitúcia poskytne Sponzorovi alebo spoločnosti INC Research možnosť zoznámiť sa s obsahom povolenia využitia osobných údajov a odsúhlasiť ho (vrátane všetkých revízií, ktoré budú vykonané počas Skúšania), a to pred tým, než sa použijú.
Authorization to Use and Disclose Health Information. Institution and Principal Investigator shall provide an appropriate privacy notice to each Trial Subject and obtain a written privacy 10.1
Authorization to Use and Disclose Health Information. I authorize Xxxxxxxx Xxxxxx, MD, PA to use and disclose all health and medical information relevant to my diagnosis and treatment Name of Patient to the following: For the purpose of diagnosis and Name of Recipient treatment of my medical condition. I also Authorize Xxxxxxxx Xxxxxx, MD, PA and his representatives to leave messages including laboratory results on my voicemail/ answering machine even if confidential information might be overheard by others than myself. Home Yes Work Yes Cell Yes No No No You have the right to revoke this authorization any time, provided that you do so in writing and accept the extent that we have already used or disclosed the information in reliance on this authorization. I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to the Authorization may be subject to redisclosure and no longer protected under federal law. By: Patient Or By: Patient’s Representative Date: Date: Description of representatives Authority: I, , authorize Xxxxxxxx Xxxxxx MD PA to furnish the above Patient information as is requested to the above Health Care Provider. Signature Date Center for Pediatric Adolescent Gynecology Xxxxxxxx Xxxxxx, MD, PA PRIVACY PRACTICES ACKNOWLEDGEMENT I have received a copy of Xxxxxxxx Xxxxxx, MD PA Notice of Privacy Practices and I have been provided the opportunity to review it. Patient Name: Birth Date: SS# Address: Signature: Patient Date: Center for Pediatric Adolescent Gynecology Xxxxxxxx Xxxxxx, MD, PA FINANCIAL RESPONSIBILITY I understand and agree to all of the following:
