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Model Template Agency Release of Information Form

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Model Template Agency Release of Information Form

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either ... Template: Client Limited Release of Information Form Created for adaptation by Julie Kunce Field, J.D ... Model Template Agency Release of Information Form

http://nnedv.org/downloads/SafetyNet/OVW/NNEDV_ClientLimitedRelease_Form_Aug08_English.doc

Date added: May 12, 2013 - Views: 45

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TENANT RELEASE AND CONSENT FORM - Mississippi Home Corporation

Title: TENANT RELEASE AND CONSENT FORM Author: Kareng Last modified by: Teri Nguyen Created Date: 2/28/2008 8:24:00 PM Company: Mississippi Home Corporation

http://www.mshc.com/compliance/pdf/FDIC/form/Household%20Egilibility%20Forms/Tenant%20Release%20and%20Consent.doc

Date added: May 17, 2013 - Views: 13

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Model Template Agency Release of Information Form

I understand that this release is valid when I sign it, and that I may withdraw my consent to this release at any time either verbally or in writing. ... Model Template Agency Release of Information Form Author: OVC Description:

http://ovc.ncjrs.gov/sartkit/tools/teamplanning/Model%20Limited%20Release%20of%20Information.doc

Date added: January 28, 2012 - Views: 107

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Section 7216 Sample Consent Forms - AICPA - American ...

However, one consent form may be used to cover what may be considered multiple “uses” of return information and another consent form to cover multiple “disclosures” of return information. In contrast, ...

http://www.aicpa.org/InterestAreas/PersonalFinancialPlanning/Membership/DownloadableDocuments/E_Alert_disc_forms.doc

Date added: October 6, 2011 - Views: 124

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CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Title: CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION Author: Robinson, David Last modified by: Robinson, David Created Date: 3/26/2007 3:50:00 PM

http://www.sumnermentalhealth.org/forms/SMHC%20CONSENT%20FOR%20THE%20RELEASE%20OF%20CONFIDENTIAL%20INFORMATION.doc

Date added: October 24, 2011 - Views: 54

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Simple release form: - Welcome to the TOPS Website

Simple release form: PHOTO/VIDEO RELEASE FORM. I hereby give permission for images of my child, captured during _____(Event) through video, photo and digital camera, to be used ... I hereby consent to the recording of statements, ...

http://www.aztops.org/Handbook/release.doc

Date added: October 31, 2011 - Views: 708

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Consent for Release of Medical Records - NC Health Literacy

Release of Medical Information. Permission to get records. I, ,with a date ... This form is only good for 3 months from the date I ... Relationship of Authorized Representative Page 2. Consent for release of medical records for (patient name) Date: Requesting records from: Name of Practice ...

http://www.nchealthliteracy.org/toolkit/tool11E.doc

Date added: April 6, 2012 - Views: 168

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AUTHORIZATION TO RELEASE MEDICAL INFORMATION

You can fill this form in on the computer for printing. When filling in the form on the computer, ... (HIPAA) requires an Authorization to Release Medical Information in order for health care providers to release medical information or records.

http://www.awppw.org/docs/Generic.HIPAA.authform.doc

Date added: October 13, 2011 - Views: 1062

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CONSENT FORM TEMPLATE - WIRB Home

I confirm that the information in the release form and any other written information was accurately explained to, and apparently understood by, the study subject’s pregnant partner. ... CONSENT FORM TEMPLATE ...

https://www.wirb.com/Documents/PREGNANT_PARTNER_CF_Template.doc

Date added: October 17, 2013 - Views: 10

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Informed Consent Template - University of Texas at El Paso

Informed Consent Form for Research Involving Human Subjects . Protocol Title: ... Because of the need to release information to these parties, ... Informed Consent Template ...

http://research.utep.edu/Portals/99/_irb_web/irbnet%20forms/IRB-009%20Informed_Consent_Template%20051409.doc

Date added: November 8, 2012 - Views: 74

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Confidential Information Release Authorization

CONFIDENTIAL INFORMATION. RELEASE AUTHORIZATION. Completion of this form authorizes the release of information described in the section below called ... This field is a user entered text field and is editable on the template. Any information that is entered in this section that is longer ...

http://dcf.wi.gov/wisacwis/knowledge_web/training/template-mapping/templates/TM_sm09_confi_info_release_auth_sw.doc

Date added: November 17, 2011 - Views: 47

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Sample HIPAA Authorization Form - Healthport

... no information about alcohol/substance abuse, hiv/aids, or mental health will be disclosed: yes, disclose this information *_____ no, do not. disclose ... this form must be fully completed before signing ...

http://www.healthport.com/Files/Sample%20HIPAA%20Authorization%20Form.doc

Date added: February 22, 2013 - Views: 120

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STATE OF CONNECTICUT - CT.gov Portal

CONSENT FOR RELEASE OF MEDICAL RECORDS. Petition No. Birth Date: ... Petition Form.dot. Title: STATE OF CONNECTICUT Author: Cybulski, Diane Last modified by: Bailey, David Created Date: 2/5/2013 2:10:00 PM Company: State of Connecticut, DPH Other titles:

http://www.ct.gov/dph/lib/dph/ems/pdf/forms/oems_complaint_form_fillable_template.doc

Date added: March 8, 2013 - Views: 15

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REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND ...

REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION. PLEASE TYPE ... personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the ... AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION Author:

http://www.backgroundsonline.com/email/Release_Form_Template.doc

Date added: May 25, 2013 - Views: 10

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CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN ...

This authorization and consent for release of personal information acknowledges that _____ (Hereafter referred to as "Company") and/or its agent, Secure Search, may now, or at any time I am assigned to, volunteer with or am employed by this Company ...

http://media.salemwebnetwork.com/JobSites/Shared/SecureSearch/Sample_Background_Consent_Form_Template_2_page_Secure_Search.doc

Date added: September 24, 2011 - Views: 172

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YA 0055 - Authorization for Release of Information

You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws. (SEE ... AUTHORIZATION FOR RELEASE OF INFORMATION State of Oregon. OREGON YOUTH AUTHORITY DISTRIBUTION ...

http://www.oregon.gov/OYA/docs/Auth_Release_Information.doc

Date added: October 7, 2011 - Views: 178

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Background Screening Consent - Salem Web Network

Applicant should complete all relevant information and sign and date the form. I, ... I release _____ and its agents and any person or entity, which provides information ... Background Screening Consent Author: Secure Search Last modified by: sdurie Created Date:

http://media.salemwebnetwork.com/JobSites/Shared/SecureSearch/Sample_Background_Consent_Form_Template_1_page_Secure_Search.doc

Date added: October 12, 2011 - Views: 49

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Microsoft Word - Medical Informed Consent Template.doc

... the researchers would release information to protect you or another person. ... the witness attests that the information in the consent form and any other written information was accurately explained to, ... Medical Informed Consent Template.doc ...

http://researchcompliance.uc.edu/Libraries/Human_Subjects_Research_IRB_Documents/Informed_Consent_Medical_Template_03-15-2011.sflb.ashx

Date added: June 3, 2012 - Views: 35

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The Family Educational Rights and Privacy Act of 1974 (FERPA ...

The FERPA Release template is located below. If a department wants to use the template, ... states: The written consent must: 1) specify the records that may be disclosed; 2) State the purpose of the ... This release form allows for the identification of the specific information to be ...

http://security.calpoly.edu/docs/forms/FERPA-Release-Dept.doc

Date added: December 14, 2011 - Views: 39

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CONSENT FORM TEMPLATE - Boston University Medical Campus

Title: CONSENT FORM TEMPLATE Subject: FOR WIRB TO WRITE Author: mcclear Keywords: 060499001 Description: updated for impwit default 062702 lomc update consent section per EPC 04182002 lomc updated consent section 011502 lomc updated with conf addition 10162001 lomc updated with IRB definition ...

http://www.bumc.bu.edu/irb/files/2002/10/BUMC-WIRB-ICF-Template.doc

Date added: March 19, 2013 - Views: 13

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Supervised Visitation Program - The Institute for Family ...

Sample Template: Consent to Release Confidential Information. I, ... born _____, do hereby consent and authorize (name of Program) to ... All Visitation Programs are different. Before you circulate a release form, ...

http://familyvio.csw.fsu.edu/wp-content/uploads/2012/04/Sample-Template-Consent-to-Release-Confidential-Information.doc

Date added: May 13, 2013 - Views: 14

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HORIZON HOUSE, INC - IBHP

AUTHORIZE _____TO RELEASE INFORMATION TO: ... This form has been fully explained and I certify that I understand its contents. I understand that (agency) ... “I understand the nature of the release and freely give oral consent ...

http://www.ibhp.org/uploads/file/HealthCenterPrimaryCareProviderConsentFinalTemplate.doc

Date added: May 10, 2013 - Views: 4

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HIPAA Authorization Template - University of Washington

The research consent form describes who will have access to your information. ... You give your permission to release your information by signing this form. ... HIPAA Authorization Template Author: Karen Moe with HIPAA compliance office Keywords: template, ...

http://www.washington.edu/research/hsd/docs/866?dl=true

Date added: January 28, 2012 - Views: 85

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Parental Waiver, Release of Liability, Indemnification and ...

Title: Parental Waiver, Release of Liability, Indemnification and Consent Form Last modified by: Secretary Created Date: 3/31/2005 8:24:00 PM Other titles

http://www.nbba.org/forms/Parental%20Waiver%20for%20minors.doc

Date added: January 27, 2012 - Views: 75

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TEMPLATE Consent Form, Standard - University of Washington

Title: TEMPLATE Consent Form, Standard Author: Helen McGough Keywords: consent, template, sample Last modified by: sherrye Created Date: 5/25/2012 3:53:00 PM

http://www.washington.edu/research/hsd/docs/555?dl=true

Date added: April 28, 2012 - Views: 8

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The following template is intended to facilitate your ...

The following template is intended to facilitate your development of an adequate informed consent form. Consent Form. title of study (insert ... This does not waive any of your legal rights nor release any claim you might ... The following template is intended to facilitate your ...

http://www.liberty.edu/media/9997/consenttemplate.doc

Date added: May 5, 2013 - Views: 10

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CONSENT TO SHARE CONFIDENTIAL INFORMATION

... health records, attendance records, test scores, copy of birth certificate, copy of physical for athletics and ISBE Form 33-78. _____ All ... I understand that this release of information is in effect ... and that I may withdraw consent for this release at any time ...

http://www.kasec.org/scripts/templates/CONSENTTOSHARE.doc

Date added: February 13, 2012 - Views: 29

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Patient Testimonial Release Form - American Osteopathic ...

Patient Testimonial Release Consent. Purpose of Consent: By signing this form, you are consenting to the American Osteopathic Association’s (AOA) use and disclosure of the information in your testimonial and acknowledgement that the testimonial may be distributed to the public.

http://www.osteopathic.org/osteopathic-health/about-dos/what-is-a-do/testimonials/Documents/patient-testimonial-form.doc

Date added: February 10, 2012 - Views: 36

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Model Template Agency Release of Information Form

CONSENT TO RELEASE INFORMATION TO THE PREA SART TEAM. A WAIVER OF CONFIDENTIALITY. Information about . The PREA SART Team: PREA SART means Prison Rape Elimination Act Sexual Abuse Resource Team. ... Model Template Agency Release of Information Form Author: OVC

http://www.prearesourcecenter.org/sites/default/files/library/newhampshireconfidentialitywaiver.doc

Date added: May 3, 2013 - Views: 10

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

of a written request to revoke and a copy of the executed authorization form to be revoked at the following address: 706 Walnut Street, ... A photostatic copy of this consent is as valid as the original. ... AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION ...

https://www.rastn.com/uploads/forms/Mental%20Health%20Authorization.doc

Date added: December 1, 2011 - Views: 14

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TEMPLATE: Short Form Subject Information and Consent Form ...

Title: TEMPLATE: Short Form Subject Information and Consent Form Template Author: Heather Kim Description: 18 FEB 2014 Last modified by: Heather Kim

http://www.cgirb.com/wp-content/uploads/_form_word_doc/CGI-502%20TEMPLATE%20-%20Short%20Form%20Subject%20Information%20and%20Consent%20Form%20Template-2101.doc

Date added: March 17, 2014 - Views: 3

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Employment Verification Form - Texas Department of Housing ...

My signature here or on the attached “Release and Consent Form” authorizes the release and/or verification of my employment information. _____ _____ _____ Applicant/Resident Printed Name Signature ...

http://www.tdhca.state.tx.us/pmcdocs/EmployVer.doc

Date added: October 24, 2012 - Views: 22

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INFORMED CONSENT FOR PARTICIPATION - Exercise is Medicine

I hereby consent to voluntarily engage in an acceptable plan of personal fitness training. ... CONFIDENTIALITY AND USE OF INFORMATION. ... I have read this Informed Consent form, ...

http://www.exerciseismedicine.org/documents/Consent_6.doc

Date added: September 15, 2011 - Views: 155

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Authorization to Use and Release Personal Health Information ...

... (Release) Protected Health Information for a Research Study. Study Title: Principal Investigator ... This Privacy Rule authorization template is designed used as a free-standing form, separate from the research consent form. Template Language/Authorization to Use or Release PHI / 3-1-12 Page ...

http://www.hawaii.edu/irb/download/documents/Privacy_Rule_Authorization_CF_Template.doc

Date added: May 2, 2013 - Views: 45

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CONSENT FORM TEMPLATE - Research

RESEARCH SUBJECT INFORMATION AND CONSENT FORM. TITLE: PROTOCOL NO.: WIRB® Protocol # Institution ... The certificate protects against the involuntary release of information about subjects collected during the course of this ... CONSENT FORM TEMPLATE Subject: working template for publication to ...

http://www.research.drexel.edu/forms/compliance/irb/wirb/WIRB_consent_template.doc

Date added: June 29, 2012 - Views: 22

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CONSENT FORM AND INFORMATION ABOUT - Greenville Memorial Hospital

Title: CONSENT FORM AND INFORMATION ABOUT Author: AORClient Workstation Last modified by: GHS Created Date: 4/17/2012 1:44:00 PM Company: American Oncology Resources

http://www.ghs.org/upload/docs/Research%20and%20Clinical%20Trials/Revised_IRB_C_Consent_Template_final_040912.doc

Date added: May 6, 2013 - Views: 8

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SCHOOL COUNSELING RELEASE FORM - Wikispaces

The bottom portion of this consent form may be returned to Ms. Bova , Mr. West, or to your child’s teacher. ... SCHOOL COUNSELING RELEASE FORM ...

http://schoolcounseling.wicomico.wikispaces.net/file/view/2010-2011+Consent+Form.doc

Date added: September 7, 2011 - Views: 91

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CONSENT TO PARTICIPATE IN A RESEARCH STUDY

This form provides an explanation about the use and disclosure ... The VHA Handbook 1605.1, Privacy and Release of Information, ... CONSENT TO PARTICIPATE IN A RESEARCH STUDY Author: Rachel Nosowsky Last modified by:

http://www.atlanta.va.gov/Docs/EIRB_HIPAA_Authorization_Template_Final.doc

Date added: May 4, 2013 - Views: 2

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Client Release Form - Body Mechanix

I understand that information exchanged during any massage session is educational in nature and is intended to help me become more familiar with and conscious of my own health status and is ... Consent to Treatment of ... Client Release Form Author: melodyherrin Last modified by: melodyherrin ...

http://bodymechanixmassage.com/sitebuildercontent/sitebuilderfiles/massage_client_release_form.doc

Date added: November 27, 2011 - Views: 103

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Informed Consent Template (Portland VA Medical Center)

Title: Informed Consent Template (Portland VA Medical Center) Subject: Informed Consent Template Author: vhaporouslep Keywords: consent form, ICF, informed consent, template

http://www.portland.va.gov/research/documents/irb/va-informed-consent.doc

Date added: February 1, 2012 - Views: 47

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Caregiver Consent Form - Arizona State University

Title: Caregiver Consent Form Author: Preferred Customer Last modified by: mmduane Created Date: 4/19/2006 6:06:00 PM Company: Arizona State University

http://www.asu.edu/studentaffairs/reslife/family/docs/Caregiver%20Consent%20Form%20for%20Medical%20Treatment.doc

Date added: October 2, 2011 - Views: 797

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CONSENT FORM AND INFORMATION ABOUT - Greenville Memorial Hospital

Title: CONSENT FORM AND INFORMATION ABOUT Author: AORClient Workstation Last modified by: WHITAKER, STACY Created Date: 12/13/2013 7:54:00 PM Company

http://www.ghs.org/upload/docs/Research%20and%20Clinical%20Trials/Phase_I_IRCOR_CF_Template_redline%20version_120613.doc

Date added: January 14, 2014 - Views: 1

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ADDENDUM TO INFORMED CONSENT FORM - University of South Dakota

Authorization (Permission) to Use or Disclose (Release) Identifiable Health Information for Research. What is the purpose of this form? Researchers would like to use your health information for research. ... ADDENDUM TO INFORMED CONSENT FORM ...

https://www.usd.edu/research/research-and-sponsored-programs/upload/InformedConsentTemplateHIPAAAddendum.doc

Date added: March 20, 2012 - Views: 6

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Informed Consent Template - Spectrum Health System | Grand ...

HIPAA Authorization for Release of Health Information for. ... Contact the investigator for more information. By signing this consent form you will not be waiving any of your legal rights which you otherwise ... There are five signature block examples attached to this template consent.

http://www.spectrumhealth.org/documents/research/forms/Informed%20Consent%20Template.doc

Date added: November 19, 2011 - Views: 23

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Consent to Form - EXPLORATORIUM ACADEMY

(template). You may mail and/or e-mail to: [email protected] ... To Release, Convey, and/or Request Student Information . I, ... Consent to Form Last modified by: Dr. Melvin Alonza Lowe, III Company:

http://www.hillandloweeducationalservices.org/images/Transcript%20Request%20Forms%202012.dotx

Date added: January 23, 2013 - Views: 6

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Informed Consent Template - Furman University

Instructions for consent form: 1) The purpose of this template is to assist investigators and other research personnel in creating informed consent documents and to facilitate consistency and accuracy of informed consent language ... Because of the need to release information to these ...

http://www2.furman.edu/sites/IRB/information/Documents/Informed_Consent_Template%20.doc

Date added: March 15, 2014 - Views: 5

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AUTHORIZATION for RELEASE of INFORMATION - Tufts University

The RAF and the informed consent form ... separate documents. This RAF template has been reviewed by the Privacy Officers for Tufts Medical Center and TUHS, ... Research Authorization Form for Limited Release of. Protected Health Information. Title of study: Principal Investigator:

http://viceprovost.tufts.edu/HSCIRB/files/RAF.doc

Date added: October 5, 2012 - Views: 82

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Authorization for Release of Information

... I have the right not to consent to the release of my educational records. 2. ... A photocopy of this Form will be treated as an original signature by Iowa State University. ... Authorization for Release of Information ...

http://www.engineering.iastate.edu/ecs/files/2012/08/a-FERPA-Authorization-Template-NEW.doc

Date added: November 8, 2012 - Views: 11

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Consent Template - United States Department of Veterans Affairs

... (PHI). We have asked you to take part in the study listed above. This form explains the use and release of your PHI for research. ... VA Department of Veterans Affairs RESEARCH CONSENT FORM (Page 4 of 4) Subject Name: Date: Title of ... Consent Template ...

http://www.northerncalifornia.va.gov/northerncalifornia/services/rnd/docs/Authorization_PHI.doc

Date added: May 22, 2013 - Views: 5

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About This Consent Form - Partners HealthCare

This consent form template may be used as the starting point for preparing consent forms for studies that involve the collection and storage of ... This form also allows release of medical record numbers to other Partners investigators provided the investigators ... Consent Form Path/File ...

http://healthcare.partners.org/phsirb/irbforms/Consent_Templates_and_Instructions/PHS_Research_Consent_Form_Tissue_Bank.02.2010.doc

Date added: November 28, 2011 - Views: 22