Research Consent and Authorization Helix Research Network( HRN)
OR REVIEW ONLY
IRB APPROVED May 19, 2025
Principal Investigator. If you withdraw your permission, you will not be able to continue being in the research study.
What happens if I want to withdraw my authorization? Information that has already been gathered may still be used and given to others. If you withdraw your permission, no new PHI will be gathered.
Will my authorization expire? This Authorization will continue until the end of the study, unless you withdraw it in writing before then. For sites in California, Delaware, Indiana, Illinois, and Washington, this permission will be good until December 31, 2070.
Documentation of Authorization:
● My signature below indicates I authorize you to use and disclose PHI about me for this study, as you have explained in this document.
____________________________ Printed Name of Participant
____________________________ Signature of Participant
____________________________ Date
Version 7, 02 / 17 / 2025 Page 18 of 18 Renown V2, 05 / 07 / 2025