Tip for Institution-specific

This is separate from the informed consent — it specifically covers your health information privacy rights

Tip for Institution-specific

You have the right to revoke this authorization at any time, though it won't affect information already disclosed

Tip for Institution-specific

The authorization must specify what information is used, who receives it, and for how long

Clinical Trialseasy

HIPAA Authorization for Research

Institution-specific · Research institution

Separate authorization for use and disclosure of PHI for research purposes. May be broader than clinical HIPAA authorization.

Form Details

Total fields: 20
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Where to Submit This Form

🏢

Sign at the research site, typically alongside the informed consent form

This authorization is required by HIPAA before your protected health information can be used for research.

Required Attachments

📎 HIPAA authorization form approved by the IRB
📎 Description of the specific health information to be used or disclosed
📎 Identification of who will receive and use the information

Processing Time

Immediate upon signing. Researchers can access your specified health information after authorization is documented.

What Happens Next

The research team can access and use your protected health information as described in the authorization. You will receive a copy. You can revoke the authorization at any time in writing, but revocation does not affect information already collected.

Tips for This Form

✓ This is separate from the informed consent — it specifically covers your health information privacy rights
✓ You have the right to revoke this authorization at any time, though it won't affect information already disclosed
✓ The authorization must specify what information is used, who receives it, and for how long
✓ Revoking the HIPAA authorization may require you to withdraw from the study

More Clinical Trials Forms

Informed Consent Document (ICF)

Study-specific · Study sponsor / institution

Comprehensive document explaining the clinical trial: purpose, procedures, risks, benefits, alternatives, voluntariness, and right to withdraw. Must be approved by IRB.

Eligibility Screening / Inclusion-Exclusion Checklist

Study-specific · Study sponsor

Checklist confirming the participant meets all inclusion criteria and no exclusion criteria for the clinical trial.

Individual Patient Expanded Access IND Application

FDA Form 3926 · U.S. Food and Drug Administration

Simplified form for requesting compassionate use of investigational drugs for patients with serious or life-threatening conditions and no alternatives. FDA approves over 99% of requests. Requires manufacturer agreement to provide the drug.

Investigational New Drug Application (IND)

FDA Form 1571 · U.S. FDA

Traditional IND application form for expanded access submissions. Form 3926 is the simplified alternative for individual patients.

Statement of Investigator

FDA Form 1572 · U.S. FDA

Statement of investigator qualifications and commitment to conduct the study per FDA regulations. Accompanies IND submissions.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Research institution or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.