AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR CLINICAL RESEARCH SCREENING AND PARTICIPATION

Health Insurance Portability and Accountability Act (“HIPAA”) Authorization

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and related privacy laws protect the privacy of your medical records and other protected health information (“PHI”). This Authorization explains how your PHI may be used and disclosed in connection with your potential or actual participation in clinical research studies conducted by or through Physicians Research Group II, LLC (“PRG”) and affiliated research sites.

I voluntarily express interest in, request information regarding, and/or am being considered for participation in one or more clinical research studies. I understand that determining my eligibility for a clinical study and/or facilitating my participation may require the use and disclosure of my protected health information.

Authorization to Release Protected Health Information

I hereby authorize my physician(s), healthcare provider(s), hospital(s), medical practice(s), pharmacy(ies), laboratory(ies), imaging center(s), surgery center(s), insurer(s), and their respective clinical and administrative staff to disclose my protected health information to:

Physicians Research Group II, LLC (“PRG”), its affiliated research sites, physician investigators, research staff, authorized representatives, and network clinical trial partners involved in evaluating or conducting clinical research studies.

PRG Contact Information
Physicians Research Group II, LLC
1351 N. Alma School Road, Suite 250
Chandler, AZ 85224
Phone: (800) 774-1534
Fax: 480-436-6676
Email: recruitment@prgresearch.com 

Information Authorized for Disclosure

I authorize the disclosure of medical information reasonably necessary to evaluate my eligibility for, enrollment in, participation in, or follow-up related to clinical research studies, including but not limited to:

• Medical diagnoses and medical history
• Physician notes and treatment records
• Surgical and procedure records
• Laboratory, pathology, and diagnostic imaging results
• Medication history and allergies
• Demographic and contact information
• Insurance information, where relevant to study-related eligibility or reimbursement review
• Other healthcare information reasonably necessary to determine my eligibility for clinical research participation or monitor study-related health matters

Minor Participants

If I am the parent or legal guardian of a minor being evaluated for or participating in a clinical study, I authorize the disclosure of the minor participant’s protected health information reasonably necessary for research screening, eligibility determination, participation, and study follow-up.

Purpose of Disclosure

I understand that my protected health information may be used and disclosed for purposes relating to:

• Evaluation of eligibility for clinical research studies
• Determination of qualification for research participation
• Study screening, recruitment, and enrollment activities
• Conduct of clinical research studies Safety monitoring and follow-up related to research participation
• Communication regarding current or future research studies for which I may qualify

I understand that my eligibility for participation in a clinical study may depend upon information obtained through this Authorization. I understand that refusal to authorize release of relevant medical information may affect my eligibility for participation in certain clinical studies.

Authorization to Contact Me Regarding Clinical Research
I authorize PRG, affiliated investigators, research staff, and authorized research partners to contact me regarding my potential eligibility for current or future clinical research studies.

I understand that contact may occur through:

• Telephone call
• Text message (SMS)
• Email
• Mail
• Patient portal or other reasonable communication methods

Consent to Receive Text Messages (SMS)

By signing this Authorization, I expressly consent to receive text messages (SMS), including autodialed or prerecorded messages where permitted by law, from Physicians Research Group II, LLC (“PRG”), affiliated research sites, investigators, and research staff regarding:

• Clinical research opportunities
• Study eligibility screening
• Follow-up communications related to research participation
• Research-related updates or requests for information

I understand that text messages may be sent to the mobile phone number(s) I provide and may contain limited health-related information reasonably necessary for research screening and participation. I understand that standard message and data rates from my wireless carrier may apply.

I understand that consenting to receive text messages is voluntary and that I may opt out of future text communications at any time by replying “STOP” to a text message or by contacting PRG directly. I understand that opting out of text messages will not affect my medical care but may limit PRG’s ability to communicate with me regarding research opportunities or participation.

Compensation Disclosure

I understand that physician investigators, research sites, and/or affiliated research organizations may receive compensation from research sponsors, contract research organizations (“CROs”), or other third parties for conducting clinical research activities associated with studies in which I may participate.

Expiration of Authorization

This Authorization shall remain valid for:

Five (5) years from the date of signature below, or one (1) year following completion of my participation in a clinical research study, whichever period is longer, unless revoked earlier in writing as described below.

Right to Revoke Authorization

I understand that I may revoke this Authorization at any time by providing written notice to:

Physicians Research Group II, LLC
1351 N. Alma School Road, Suite 250
Chandler, AZ 85224

I understand that revocation will not apply to information already used or disclosed in reliance upon this Authorization prior to receipt of my revocation.

Redisclosure of Information

I understand that information disclosed pursuant to this Authorization may no longer be protected by HIPAA and may be subject to redisclosure by the recipient to the extent permitted by applicable law. However, PRG and affiliated research personnel will make reasonable efforts to protect the confidentiality of my information in accordance with applicable privacy laws and research requirements.

I understand that signing this Authorization is voluntary.

By signing below, I acknowledge that I have read and understand this Authorization and voluntarily authorize the use and disclosure of my protected health information as described herein.