The Health Insurance Portability and Accountability Act (HIPAA) of 1996 allows, in limited circumstances and with appropriate approvals, disclosure of Protected Health Information (PHI) by a Covered Entity without the patient’s explicit authorization for research purposes (45 CFR 164.512(i)). However, these disclosures must be tracked through an Accounting of Disclosures documentation process (45 CFR 164.528(b)(4)(i)). At UMass Medical School/UMass Memorial Health Care, if the number of disclosures is greater than or equal to 50 (individual patient records), researchers may either 1) document access to each record through the required disclosure process or 2) use a process, which Summary Accounting must contain the information requested below. Use this form if pursuant to your IRB-approved research protocol, Memorial will be disclosing 50 or more records to you for research purposes. UMass Medical School, the entity with responsibility for approval of human research activities, has agreed to assist UMass Memorial in facilitation of the summary disclosure accounting process. Individual completing the form: Contact information: Telephone: Email: Project Docket # PI Name, Plain Criteria for PHI to be Type of Waiver Sponsor Time Frame Name Address & language, selecting Accessed (check applicable, below) Name, (access start & Contact short particular (i.e. Address & projected stop Phone # description of records (i.e. Demographics, Contact and purpose diabetics with labs, imaging) Phone # to for research (mm/dd/yyyy) Partial Waiver for Recruitment/Participant Identification Full Waiver Other: Please complete and return this form via email to: The above information will be stored by UMass Medical School and provided to individuals in coordination with UMass Memorial Health Care upon request. If there are any changes to the above information during the course of the research, or if you have any questions about disclosure accounting requirements, please contact the UMMS Sr. Privacy Officer at the email above or by calling (508) 856-5508.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 allows, in limited circumstances and with appropriate approvals, disclosure of Protected Health Information (PHI) by a Covered Entity without the patient’s explicit authorization for research purposes (45 CFR 164.512(i)). However, these disclosures must be tracked through an Accounting of Disclosures documentation process (45 CFR 164.528(b)(4)(i)). At UMass Medical School/UMass Memorial Health Care, if the number of disclosures is greater than or equal to 50 (individual patient records), researchers may either 1) document access to each record through the required disclosure process or 2) use a Summary Accounting process, which must contain the information requested below. Use this form if pursuant to your IRB-approved research protocol, Memorial will be disclosing 50 or more records to you for research purposes. UMass Medical School, the entity with responsibility for approval of human research activities, has agreed to assist UMass Memorial in facilitation of the summary disclosure accounting process. Individual completing the form: Contact information: Telephone: Email: Project Name Docket # PI Name, Address & Contact Phone # Plain language, short description of and purpose for research Criteria for selecting particular records (i.e. diabetics with PHI to be Accessed (i.e. Demographics, labs, imaging) Type of Waiver (check applicable, below) Sponsor Name, Address & Contact Phone # Time Frame (access start & projected stop to (mm/dd/yyyy) Partial Waiver for Recruitment/Participant Identification Full Waiver Other: Please complete and return this form via email to: The above information will be stored by UMass Medical School and provided to individuals in coordination with UMass Memorial Health Care upon request. If there are any changes to the above information during the course of the research, or if you have any questions about disclosure accounting requirements, please contact the UMMS Sr. Privacy Officer at the email above or by calling (508) 856-5508.
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