Introduction: You have the right to decide who may review or use your Protected Health Information ("PHI"). The type of information that may be used is described below.
Acknowledgment: I have recovered from COVID-19 and I am interested in donating plasma that will be administered as part of a research study. The purpose of the study is to see if the antibodies in my plasma help other patients to recover. I understand that more information is needed to determine if I can donate plasma for COVID-19 treatment than with a normal plasma donation.
PHI Uses/Disclosures: I authorize Franciscan Health:
- To obtain my COVID-19 test results from my medical record
- To disclose those results as well as the information I provided in the previous questionnaire (demographic information, responses to questions about current and past COVID-19 symptoms, disease history that could impact donation ability, etc.) to Versiti (plasma donation center).
I have the right:
To refuse to sign this form. Not signing the form will not affect my regular health care including treatment, payment, or enrollment in a health plan or eligibility for health care benefits. However, not signing the form may prevent me from donating plasma for COVID-19 treatment.
To review and obtain a copy of my personal health information collected during the research study.
To cancel this release of information/authorization at any time. If I choose to cancel this release of information/authorization, I must notify in writing at: Franciscan Health, Attn: Legal Department, 421. N Emerson Avenue, Greenwood, IN 46143. However, even if I cancel this release of information/authorization, information may already have been shared.
To receive a copy of this form upon request.
Due to the COVID-19 pandemic, it was not recommended that the individual present at Franciscan Health to complete this paperwork. I have had the opportunity to review and ask questions regarding this release of information/authorization. By electronically signing this release of information/authorization, I am confirming that it reflects my wishes.