UW Research

Forms and Templates

PAPER SUPPLEMENT: Waiver Request, HIPAA Authorization


Use this form to request a waiver of the requirement for HIPAA Authorization. This means that you are requesting permission to access, obtain, use or disclose a research subject’s Protected Health Information (PHI) for research purposes without obtaining the subject’s specific authorization for that access, use or disclosure.

This document is for use with paper-based applications only. Do not use with Zipline. HSD accepts versions from 3/27/2015 on.

Change Notes

Revised instructions to describe email submission process – 03.12.2020
Removed all references to Confidentiality Agreements and to state law RCW 42.48 – 07.28.2019
Updated links – 05.09.2017