Research Consent and Authorization Helix Research Network( HRN)
OR REVIEW ONLY
IRB APPROVED May 19, 2025
Authorization to Use and Disclose Health Information In order to conduct the research study described in this form, the Principal Investigator and study staff must obtain, use, and share personal information about you, including your health information and information that can identify you. Protected health information( PHI) is information about your health or your medical care that was collected by a healthcare provider that can be used to identify you. Renown Health or its study partners where you are participating in this study is required by law to protect your health information and must have your permission to use or share health information that identifies you for this research study.
What PHI will be shared?
● Existing and future medical records and the data contained within such records, including mental health records and other records linked to your medical records
● New health information created from study-related tests, procedures, visits and / or questionnaires.
● The information you give will include your entire medical record. This includes the following information. If you do not want to share this information, you should not participate in the study.
● Information pertaining to drug and alcohol abuse, diagnosis or treatment.
● Information pertaining to HIV / AIDS testing and treatment.
● Genetic testing information.
● Information pertaining to mental health diagnosis or treatment.
Your PHI will be shared in order to do the following:
● Conduct the research as described in this form, including future research and related research
● To contact you about future research studies
● For purposes of creating a Helix account
● To ensure the research meets legal and other requirements
● Conduct public health activities which include reporting of adverse events or situations where you may be at risk or harm
Version 7, 02 / 17 / 2025 Page 16 of 18 Renown V2, 05 / 07 / 2025