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.