By submitting the Patient Profile Questionnaire on this website,
you are submitting certain personal information to this website
for purposes of being considered by HIFU MX and its panel of physicians
and other affiliated researchecors to determine if you are eligible
for participation in clinical research studies either within or
outside of the United States.
The Standards for Privacy of Individually Identifiable
Health Information under the Administrative Simplification subtitle
of the Health Insurance Portability and Accountability Act of
1996 (HIPAA) set forth at 45 CFR Parts 160 and 164 (the “Privacy
Rule”) permit that for activities involved in preparing
for research, covered entities may use or disclose your protected
health information (PHI) to a researcher without your authorization.
To the extent that HIFU MX is a covered entity for purposes of the
Privacy Rule, HIFU MX will obtain from its affiliated researchers
either oral or written representations that:
(1) the use or disclosure is requested solely to review PHI as
necessary to prepare a research protocol or for similar purposes
preparatory to research,
(2) the PHI will not be removed from the covered entity in the
course of review, and
(3) the PHI for which use or access is requested is necessary
for the research. We may permit the researcher to make these representations
in written or oral form.
Under the preparatory to research provision, we
may permit a researcher who works for HIFU MX to use PHI for purposes
preparatory to research. We may also permit, as a disclosure of
PHI, a researcher who is not a workforce member of HIFU MX to review
PHI (within that covered entity) for purposes preparatory to research.
The Privacy Rules also permits a researcher to contact you to
seek your authorization for the use or disclosure of your PHI
for research purposes. If you are selected to participate in any
clinical research sponsored by HIFU MX, you will be asked to sign
an authorization before your PHI is used for research purposes
and will also be asked to sign an informed consent to participate
in the research.
By providing your personal information, and clicking
on the SUBMIT button of the form, you acknowledge your understanding
of, and agree to the use of your PHI under, the conditions contained
in this paragraph.