Online Medical Consent Form

Authorization for Use/Disclosure of Health Information:

I hereby authorize health information which includes the patient's entire medical record, including Protected Health Information, Sensitive Health Information and diagnosis formation relating to any medical history, mental or physical condition, and any treatment received by the patient, to be released by all medical providers including the provider below:

To The Following Individual:

Tandem Clinical Research

Purpose:

I authorize the release of the written health information and exchange of oral communication patient health information for the purpose of continuity of care or record review for research study participation.

Information to be Disclosed and Exchanged:

I authorize the release of all of the patient health information that any provider has in his or her possession, including information relating to any medical history, mental or physical condition, and any treatment received by me. This includes but is not limited to office visit notes, progress notes, and laboratory results.

Expiration of Authorization:

Unless otherwise revoked, this authorization does not expire except in states where unlimited authorization is not permitted, in which case it expires 50 years from the date of signature.

Notice:

Tandem Clinical Research and many other organizations and individuals, such as physicians, hospitals, and health plans, are required by law to keep your health information confidential. However, information disclosed under this authorization might be redisclosed by the recipient, and the redisclosure may no longer be protected by federal or state law.

Refusal to sign/Right to Revoke:

I understand that this authorization to release health information is voluntary. I can revoke this authorization by providing a written notice of revocation to the address listed below. Revocation will be effective upon Tandem Clinical Research’s receipt and will not have any effect on any action taken in reliance of this Authorization before written notice of revocation was received. I need not sign this form to ensure healthcare treatment from a healthcare or medical facility or provider. I understand that I have a right to receive a copy of this form and that it is made accessible to me.

Questions:

I understand that I may contact Tandem Clinical Research for answers to the patient questions about this form at 1151 Barataria Boulevard, Suite 3200, Marrero, LA 70072 or by telephone at (407) 801-4438.