RSRB Feedback Form
HIPAA Authorization for the Release of Medical Information
To ensure that the nine required elements of a HIPAA compliant authorization are contained in release of information requests, the Authorization Form SH 48 may not be altered, with the exception of the contact information in the upper right-hand corner. Please call Brenda Tryon at L.L. Donnelly at 249-7703 to provide the appropriate contact information for your study and to order the forms.
A sample of this form can be viewed here.