Authorization Cover Letter Template printable pdf download

Authorization Cover Letter Template

PPENDIX

UTHORIZATION

OVER

ETTER

EMPLATE

<< Letterhead of NLST Screening Center >>

National Lung Screening Trial (NLST)

<< Date >>

<< Participant Name >>

<< Participant Address >>

Dear << Participant Title >> <<Participant Name >>,

Thank you for your continued participation in the National Lung Screening Trial!

Our records show that since the time you started with the NLST, you have had a lung-related surgical

procedure. We would like to obtain a small amount of the surgical material (also known as a pathology

specimen) that was removed and preserved after your procedure. This will help future cancer research.

To allow us to obtain the material from the pathology lab, please sign the <<Authorization Form(s)>> included

with this letter. We have enclosed two copies of the form. Please read, sign, and return one copy to us in the

enclosed postage paid envelope. The other copy is for your records.

As you know, you have already given us consent for your involvement in NLST, but because of important

HIPAA laws that are designed to protect the privacy of your medical information, we are asking for this

additional authorization to obtain a portion of the pathology specimen from the pathology lab.

If you have any questions about this request or the NLST study, please call me or your NLST study

coordinator, << study coordinator >>, at << phone number>>. Thank you very much for your help with our

continuing research.

Sincerely,

<< NLST Site PI >>

<< NLST Site PI Title >>

<< NLST Site >>

Enclosures:

Authorization Form (two copies)

Self-addressed, stamped return envelope

Page 11 of 17

Authorization Cover Letter Template