Authorization for the Release of Health Information from Other Healthcare Facilities

MAIL RECORDS TO: PIONEER RESEARCH 9159 SW 87th Ave, Miami, FL 33176

PHONE: 305-420-5541

FAX RECORDS TO: 1-305-420-6949

I hereby authorize each and every physician, hospital, clinic, laboratory, pharmacy, medical examiner or coroner office, and other health care provider or facility that now holds, has held, or during the effective period of this authorization may create, receive, maintain, or otherwise hold records concerning me (or, if applicable, the deceased patient named above) to release the health information indicated below to PIONEER CLINICAL STUDIES, INC. dba PIONEER RESEARCH (the Recipient). This authorization applies to the foregoing class of persons and entities whether or not they are known to me or specifically identified at the time I sign this authorization, and includes records relating to care, treatment, testing, hospitalization, or other services provided before or after the date I sign this authorization, provided that the requested records are created, received, maintained, or held before this authorization expires or is revoked. The purpose of this disclosure is to determine my eligibility for, including screening or prescreening, and to support my participation in, clinical research studies conducted at Pioneer Research, and related medical care and safety reporting. I understand this authorization may be kept on file and used for more than one study, including studies for which I am not yet identified or enrolled. The information released in response to this authorization may be re-disclosed to other Business Associates. I understand and acknowledge that this may include treatment for physical and mental illness, genetic testing information, alcohol/drug abuse, and or HIV/AIDS test results or diagnoses. I expressly authorize the disclosure to the Recipient of any HIV test results and HIV/AIDS-related information contained in my records, as separately indicated by my initials below. This authorization does not include permission to release outpatient Psychotherapy Notes. The release of Psychotherapy Notes requires a separate authorization. Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of a patient's medical record.

Por medio de la presente, autorizo a todos y cada uno de los médicos, hospitales, clínicas, laboratorios, farmacias, oficinas del médico forense o examinador médico, y demás proveedores o centros de salud que posean expedientes relacionados conmigo (o, si corresponde, con el paciente fallecido nombrado anteriormente) a divulgar la información de salud indicada a continuación a PIONEER CLINICAL STUDIES, INC. dba PIONEER RESEARCH (el Destinatario). El propósito de esta divulgación es determinar mi elegibilidad para, incluida la selección o preselección, y apoyar mi participación en estudios de investigación clínica realizados en Pioneer Research, y la atención médica y el reporte de seguridad relacionados. Entiendo que esta autorización puede conservarse en el expediente y utilizarse para más de un estudio, incluidos estudios para los cuales aún no he sido identificado/a ni inscrito/a. La información divulgada en virtud de esta autorización podrá ser re-divulgada a otros Asociados Comerciales (Business Associates). Entiendo y reconozco que dicha información puede incluir tratamiento por enfermedades físicas y mentales, información sobre pruebas genéticas, abuso de alcohol y/o drogas, así como resultados de pruebas o diagnósticos relacionados con el VIH/SIDA. Esta autorización no incluye el permiso para divulgar las Notas de Psicoterapia ambulatoria. La divulgación de las Notas de Psicoterapia requiere una autorización por separado. Las Notas de Psicoterapia se definen como aquellas notas que documentan sesiones de consejería privadas, conjuntas, grupales o familiares, y que se mantienen separadas del resto del expediente médico del paciente.

This authorization covers all records for the date(s) of treatment specified above, including, where applicable, the death certificate, autopsy report, and medical examiner or coroner report. (Esta autorización cubre todos los expedientes correspondientes a la(s) fecha(s) de tratamiento indicadas arriba, incluyendo, cuando corresponda, el certificado de defunción, el informe de autopsia y el informe del médico forense o examinador médico.)

By initialing below, I specifically authorize each person or entity identified above to disclose to Pioneer Clinical Studies, Inc. dba Pioneer Research any HIV test results and HIV/AIDS-related information in my records for the purpose stated in this authorization. I understand that this authorization is voluntary and applies only to the disclosure of HIV test results and HIV/AIDS-related information covered by this authorization.

This consent is subject to revocation at any time, except to the extent that action has already been taken in reliance upon it, by submitting a written revocation to Pioneer Research at the address listed above. This authorization and consent will expire three (3) years from the date of authorization written below, or at the end of my participation in any research study at Pioneer Research for which these records are used (including any required follow-up), whichever is later, unless I revoke it sooner. Your health care will not be affected by whether you sign this authorization or not. Once your health care information is released, redisclosure of your health care information by the Recipient may no longer be protected by law.

Este consentimiento puede ser revocado en cualquier momento, excepto en la medida en que ya se haya actuado conforme al mismo. Esta autorización y consentimiento vencerá a los tres (3) años a partir de la fecha de autorización indicada a continuación, o al finalizar mi participación en cualquier estudio de investigación en Pioneer Research para el cual se utilicen estos expedientes (incluido cualquier seguimiento requerido), lo que ocurra más tarde, a menos que la revoque antes. Su atención médica no se verá afectada si firma o no esta autorización. Una vez divulgada su información médica, es posible que la re-divulgación de dicha información por parte del Destinatario ya no esté protegida por la ley.