Authorization to Use or Disclose (Release) 
Identifiable Health Information For Research

Institution: please address all red text. 

1.  What is the purpose of this form?

The Southwest Oncology Group is an organization that does research to learn about the causes of cancer, and how to prevent and treat cancer.  Researchers would like to use your health information for research.  This information may include data that identifies you.  Please carefully review the information below.  If you agree that researchers can use your identifiable health information, you must sign and date this form to give them your permission.

2.  What health information do the researchers want to use?

The researchers want to abstract and use the portions of your medical record that they will need for their research.  If you enter a Southwest Oncology Group research study, information that will be used and/or released may include your complete medical record, and in particular, the following:

•	the history and diagnosis of your disease
•	specific information about treatments you received
•	information about other medical conditions that may affect your treatment
•	medical data, including laboratory test results, tumor measurements, CT scans, MRIs, X-rays, photographs of radiation therapy target areas, and pathology results
•	information on side effects (adverse events) you may experience, and how these were treated
•	long-term information about your general health status and the status of your disease
•	tissue and/or blood samples, associated data related to the analysis of the samples

You may request a blank copy of the Southwest Oncology Group data forms from [title/position] to learn what information will be shared.

3.  Why do the researchers want my health information?

[name of site] will collect your health information and share it with the Southwest Oncology Group if you enter a Cooperative Group research study, or to evaluate your eligibility for a study.  The Southwest Oncology Group researchers will use your information for the following cancer research study(ies).

[title and details of study as required by your institution]

4.  Who will be able to use my health information?

[name of site] will use your health information for research.  As part of this research, they may give your information to the following Groups taking part in the research.  [name of site] may also permit staff from these Groups to review your original records as required by law for audit purposes. 

•	the Southwest Oncology Group
•	[name of participating Group, if applicable]  
•	[name of member institution, if applicable]
•	the Cancer Trials Support Unit (CTSU), a research group sponsored by the National Cancer Institute to provide greater access to cancer trials [if applicable]
•	public health agencies and other government agencies (including non-U.S.) as authorized or required by law
•	other people or organizations assisting with Southwest Oncology Group research efforts.
•	central laboratories, central review centers, and central reviewers.  The central laboratories and review agencies may also give your health information to those groups listed above.

5.  How will information about me be kept private?

The Southwest Oncology Group will keep all identifiable health information confidential to the extent possible, even though they and other federal research groups are not subject to the same federal privacy laws governing clinical centers.  The Southwest Oncology Group will not release identifiable health information about you to others except as authorized by this form, or required by law.  If your identifiable health information must be shared with other organizations, the privacy laws that govern those organizations would apply.

6.  What happens if I do not sign this authorization form?

If you do not sign this authorization form, you will not be able to take part in a research study for which you are being considered.

7.  If I sign this form, will I automatically be entered into the research study?

No, you cannot be entered into any research study without further discussion and separate consent.  After discussion, you may decide to take part in the research study.  At that time, you will be asked to sign a separate research consent form.

8.  What happens if I want to withdraw my authorization?

You can change your mind at any time and withdraw this authorization.  This request for withdrawal must be made in writing.  Beginning on the date you withdraw your authorization, no new identifiable health information will be used for research.  However, researchers may continue to use the health information that was provided before you withdrew your permission.

If you sign this form and enter the research study, but later change your mind and withdraw your authorization, you will be removed from the research study at that time.

To withdraw your authorization, please contact the person below.  [He/she] will make sure your written request to withdraw your authorization is processed correctly. 

[title of contact person, address, phone and fax number]

9.  How long will this authorization last?

If you agree by signing this form that researchers can use your identifiable health information, this authorization has no expiration date.  However, as stated above, you can change your mind and withdraw your permission at any time.

10.  What are my rights regarding my identifiable health information?

You have the right to refuse to sign this authorization form.  You have the right to review and/or copy records of your health information kept by [name of site].  You do not have the right to review and/or copy records kept by the Southwest Oncology Group or other researchers associated with the research study.

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Signatures

I agree that my identifiable health information may be used and disclosed for research purposes described in this form.

Signature of Patient or Patient's Legal Representative:

									Date: 				

Printed Name of Legal Representative (if any): 							

Representative's Authority to Act for Patient: 							

Signature of Person Obtaining Authorization: 							

Printed Name of Person Obtaining Authorization: