ࡱ>  bjbjxx jj;& 333GGG8\<G~$----!$#$#$#$#$#$#$&&(#$3@#$--m8$000^8-3-!$0!$00!`O"-P1&8 " $N$0~$#",n)Dvn)O"O"~n)3"@0#$#$v~$n) :  Consent Form - Medical Case Report ýĻƷ Medical Center (ýĻƷ Dentists, LLC (UTD) ýĻƷ Physicians, LLC (UTP) Case Report: Insert TITLE Principal Author: Name, degrees held Institution Contact Phone Number, Extension Please read this form carefully and take your time to make your decision and ask any questions that you may have. You are being asked to consider allowing Dr. (insert name) of ýĻƷ Medical Center and ýĻƷ Physicians, LLC. to use information about your (insert condition/disease/experience) to write what is called a case report. Case reports are typically used to share new unique information experienced by one patient during his/her clinical care that may be useful for other physicians and members of a health care team. A case report may be published in a medical journal in print and on the internet for others to read, and/or presented at a medical conference. Readers include not only doctors, but also journalists and other members of the public. This form explains the purpose of this case report. The purpose of this case report is to inform other physicians that (insert specific reason i.e. patients presenting to the ER with X) may be related to Y, however, was masked by a common over the counter medication Z). We believe that the material has educational or scientific value that may help to improve the care that other patients receive in the future. Your information being used for this case report includes (insert specific information here --------------------------------). We are obligated to protect your privacy and not disclose your personal information (information about you and your health that identifies you as an individual e.g. name, date of birth, medical record number). When the case report is published or presented, your identity will not be disclosed. However, the report may information such as your age, gender, and ethnic origin. NO TEXT THIS PAGE Although your personal information collected or obtained will be kept confidential and protected in accordance with the law, there is a limited risk associated with this case report that could result in a loss of confidentiality such as if your condition is rare and you have shared your medical information with others. You will not directly benefit from participating in this case report. You will not receive any compensation. Allowing your information to be used in this case report will not involve any additional costs to you. Taking part in this case report is your choice (voluntary). You will receive the same care even if decided not to participate. You may choose not to take part or you may change your mind at any time. You may revoke your consent by sending notice in writing to: (name, department, ýĻƷ, Mail Stop ______, 3000 Arlington Avenue, Toledo, Ohio 43614). However, once the case report is written and published, it will not be possible for you to withdraw it. Your decision will not result in any penalty or loss of benefits to which you are entitled including the quality of care you receive. You will be told about any new information relating to this case report that may affect you. Your signature below means that you have read the above information about this Case Report and have had a chance to ask questions to help you understand how your information will be used and that you give permission to allow your information to be used in this case report. If you have any questions now or later, please contact (insert name) at (XXX) XXX-XXXX ext XXX. CONTINUED NEXT PAGE SUBJECT CONSENT TO PARTICIPATE Case Report Title: Name of Participant: ________________________________________ Participant/Legally Authorized Representative By signing this form, I confirm that: The case report has been fully explained to me and all of my questions have been answered to my satisfaction I have had enough time to consider the information and understand that I may take additional time to decide I have been informed of the risks and benefits, if any, of allowing my information to be used in this case report I have been informed that I do not have to participate in this case report I have read each page of this form I authorize access to my personal health information (medical record) as explained in this form I have agreed to participate in this case report I am 18 years of age or over, or I am the parent or legally authorized representative of the Participant. __________________________ _______________________ _______________ _____ AM PM Name of Participant/Legally Signature Date Time Authorized Representative (print) I have carefully explained to the subject the nature of the above project. I certify that to the best of my knowledge the person who is signing this consent form understands clearly the nature, involved in his/her participation and his/her signature is legally valid. A medical condition or language or educational barrier has not precluded this understanding. __________________________ ____________________ _____________________ _____ AM PM Name of Person Obtaining Signature Date Time Consent (print) Please place a copy of this form, the Medical Case Report Consent/Authorization Form into the patients chart and send a copy to Parker, C'Shalla< HYPERLINK "mailto:CShalla.Parker@utoledo.edu" CShalla.Parker@utoledo.edu>, Privacy Officer, UTMC Compliance. MLB 0048 She keeps similar forms as cases, in the event of a breach of patient information. The Privacy Office is typically the first place everyone (including the Office of Civil Rights) looks. The attached form will work if there is a patient or authorized representative who can give consent.     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