This document fully outlines the statements and the questions that must be answered in an individual authorization according to the new regulations.

This document may need to be modified, on a state-by-state basis, to comply with the provisions of applicable state law that are not preempted by HIPAA.

Derived from the American Society of Clinical Oncology (www.asco.org)

ASCO Document #9

Patient Name: _________________________________

ID Number:____________________

(Optional) We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before signing this form.

USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION

A representative of the organization requesting the protected health information must answer these questions completely before providing this authorization form to you. DO NOT SIGN A BLANK FORM. You or your personal representative should read the descriptions below before signing this form.

Who will disclose the information? The person(s) or class of persons authorized to disclose the information are described below. 164.508 (c) (1) (iii)

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Who will use and/or receive the information? The person(s) or class of persons authorized to use and/or receive the information are described below. 164.508 (c) (1) (ii)

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What information will be used or disclosed? The description below should be in enough detail so that you (or any organization that must disclose information pursuant to this authorization) can understand what information may be used or disclosed. 164.508 (c) (1) (i)

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What is the purpose of the use or disclosure? The purposes for which the information will be used or disclosed are described below. 164.508 (c) (1) (iv)

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When will this authorization expire?¹ The date or event that will trigger the expiration of this authorization should be described below.- See: “Some Researcher-Specific Points,” and 164.508 (c) (1) (v)

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SPECIFIC UNDERSTANDINGS

By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be redisclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information. 164.508 (c) (2) (iii)

You have a right to refuse to sign this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not sign this form.² 164.508 (c) (2) (ii) (A) and (B)

You have a right to see and copy the information described on this authorization form in accordance with our record access policies. You also have a right to receive a copy of this form after you have signed it. 164.508 (c) (4)

If you sign this authorization, you will have the right to revoke it at any time, except to the extent that we have already taken action based upon your authorization. To revoke this authorization, please write to [insert name of responsible person or department]. 164.508 (c) (1) (i)

SIGNATURE

164.508 (c) (1) (vi)

I have read this form and all of my questions about this form have been answered. By signing below, I acknowledge that I have read and accept all of the above.

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Signature of Patient or Personal Representative

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Print Name of Patient or Personal Representative

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Date

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Description of Personal Representative's Authority