Confidentiality of Records and Authorization to Use and Share Health Information

If you agree to participate in this research, identifiable health information about you will be used and shared with others involved in this study. You agree to permit Crouse Hospital, your doctors and other health care providers to disclose health information in your medical records to the researchers and (study sponsor).

Individually identifiable health information that may be used and shared includes all information collected during this research study. This includes any information from your medical record, and information obtained from this study that can be associated with you.

The researchers may use and share your health information to conduct the research, share your health information with (study sponsor), or share your health information as required by law with representatives of government organizations, Crouse Hospital Institutional Review Board, and other persons who are required to watch over the safety and the process of research.

Once information that could be used to identify you has been removed, the information that remains is no longer subject to this Authorization and may be used and shared by the researchers and (sponsor) as permitted by law.

Once your health information has been shared with a third party, federal privacy laws may no longer protect it. However, the researchers and (sponsor) agree to protect your health information by using and disclosing it only as permitted by you in this Informed Consent. Also, no publication about the research will reveal your identity without your specific written permission. These limitations continue even if you revoke (take back) this authorization.

You may change your mind and take back this authorization at any time by writing to (Principal Investigator) at (address). If you do this, you will no longer be allowed to participate in the research. However, even if you take back this Authorization, the information already obtained may be used and shared as permitted by this Informed Consent.

At the end of the study, you have the right to see and copy your health information according to Crouse Hospital policies; however, your access may be limited while the study is in progress.

There is no scheduled date at which your information will be destroyed or no longer used. This is because information that is collected for research purposes continues to be used and analyzed for many years and it is not possible to determine when this will be complete.