Authorization Cover Letter Template (Page 2 of 8) in pdf

Authorization Cover Letter Template Page 2

PPENDIX

UTHORIZATION

ELEASE

URGICAL

ATERIAL

EMPLATE

<< Letterhead of NLST Screening Center >>

National Lung Screening Trial (NLST)

Authorization to Release Surgical Material & Related Health information

that Identifies You for Research

Your signature below gives permission to staff at << Pathology Lab Name >> to release surgical material (also

known as pathology specimen) and the related pathology report obtained during your diagnosis or treatment of

lung cancer or related condition. The pathology specimen will be used for research in lung cancer detection,

prevention and treatment by the ongoing National Lung Screening Trial (NLST), in which you are a participant.

This authorization is required by law to protect your health information. The pathology specimen and pathology

report will be released to your local NLST screening center, identified at the top of this form. Any identifying

information attached to the pathology specimen and pathology report such as your name, specimen ID or

medical record number will be removed or blanked out before being sent to the NLST-ACRIN Central

Laboratory located at the University of California at Los Angeles Tissue Array Core Facility. By signing this

document, you authorize << Pathology Lab Name >> to release your pathology specimen and pathology report

for this research. Your local NLST screening center will hold your health information in confidence, will use it

only for study purposes, and will not release it to anyone other than the study team unless required by law.

Only the screening center and Central Laboratory staff involved with NLST research will have access to your

pathology specimen and pathology report for this research.

Your medical treatment will not be affected in any way based on your decision to sign or not sign this

Authorization.

You may change your mind and revoke this Authorization at any time, except to the extent that any actions

have already been taken based on this Authorization. To revoke this Authorization, contact your local NLST

screening center or write to << Pathology Lab Name >>, << Pathology Lab Contact >>, << Pathology Lab

Address >>. This authorization does not have an expiration date.

Signature of Participant or

Date Signed

Participant’s Personal Representative

Printed Name of Participant or

If Applicable, Description of

Participant’s Personal Representative

Representative’s Authority

Personal

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Authorization Cover Letter Template Page 2