UW Research
Forms and Templates

HIPAA Authorization Template


The purpose of this template is to create the HIPAA Authorization form that subjects, parents, and/or legally-authorized representatives of subjects sign to give you permission to obtain and use protected health information (PHI) of subjects for research purposes.

Change Notes

Add UW Medicine Compliance email address – 11.30.2022
Replace “UW Clinical Research Center (CRC)” with “UW ITSH Adult Translational Research Unit (TRU)” – 10.27.2022
Replace “Seattle Cancer Care Alliance” with “Fred Hutchinson Cancer Center” – 06.03.2022
Add template language for providing required written notices (e.g., informing subjects how they can receive an electronic copy of the authorization form, paper copy provided at no cost, etc.) when authorization will be obtained using e-signature. – 07.22.2021