1 CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Adult Patient or Parent, for Minor Patient INSTITUTE: National Cancer Institute PRINCIPAL INVESTIGATOR: Raffit Hassan, M.D. STUDY TITLE: Tissue Procurement and Natural History Study of Patients with Malignant Mesothelioma and Other Mesothelin Expressing Cancers Continuing Review Approved by the IRB on 05/04/15 Amendment Approved by the IRB on 06/22/15 (B) Date posted to web: 07/16/2015 Standard INTRODUCTION We invite you to take part in a research study at the National Institutes of Health (NIH). First, we want you to know that: Taking part in NIH research is entirely voluntary. You may choose not to take part, or you may withdraw from the study at any time. In either case, you will not lose any benefits to which you are otherwise entitled. However, to receive care at the NIH, you must be taking part in a study or be under evaluation for study participation. You may receive no benefit from taking part. The research may give us knowledge that may help people in the future. Second, some people have personal, religious or ethical beliefs that may limit the kinds of medical or research treatments they would want to receive (such as blood transfusions). If you have such beliefs, please discuss them with your NIH doctors or research team before you agree to the study. Now we will describe this research study. Before you decide to take part, please take as much time as you need to ask any questions and discuss this study with anyone at NIH, or with family, friends or your personal physician or other health professional. If you are signing for a minor child, you refers to your child throughout the consent document. CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Adult Patient or Parent, for Minor Patient (1)
2 CONTINUATION: page 2 of 13 pages Why is this study being done? This study will allow us to collect a variety of samples from people with malignant mesothelioma or other cancer types that produce a protein called mesothelin. The tests performed on the blood, urine, abnormal body fluid and tumor biopsy samples collected on this study could provide a better understanding of the biology of mesothelioma and lead to the development of more effective strategies for treatment in the future. This is not a study to treat you. Analysis of the specimens you provide will require that we also collect some information from you or your medical record about you and your cancer, your previous treatments, and your treatment course. This information could help us understand why certain types of mesothelioma respond differently to treatment. Why are you being asked to take part in this study? You are being asked to participate in this study because you have been diagnosed with malignant mesothelioma, thymic carcinoma, pancreatic or biliary adenocarcinoma or lung, gastric or ovarian cancer. How many people will take part in this study? Up to 1000 patients may be enrolled on the study. Description of Research Study Before you begin the study Before you begin this study, you will need to have the following exams and tests to make sure you are eligible for this study. The exams and tests are part of regular cancer care and may be done even if you do not join the study. You may have already had these tests done as part of your NCI protocol. If you have recently undergone some of these tests, they may not need to be repeated. During the study History and physical examination Tests to determine your blood counts Pregnancy test in female patients (you will not be allowed on the study if the test is positive) Confirmation of pathology by NCI Laboratory of Pathology. Once it has been determined that you are eligible and agree to participate in the study, we will request that you send us tissue blocks of your primary (original) tumor, if possible, for inclusion
3 CONTINUATION: page 3 of 13 pages in our tissue bank. If tissue blocks are not available, we will request unstained slides of primary tumor tissue. We will also do the following tests at least once. If any of these tests are done as part of an NCI treatment protocol that you are enrolled in and the results are available to us, they will not be repeated for this protocol. Review your medical record, including pathology reports and imaging studies Medical History and Physical Exam Routine blood tests Blood tests to determine the levels of a protein that is secreted by mesotheliomas (mesothelin) Routine urine tests May obtain imaging scans (only if your clinical condition requires it) If you are enrolled on an NCI treatment protocol, the above tests may be performed as specified in the post-treatment follow up of that protocol and the results, if available to us, will also be included in this study. If the results of tests performed on your treatment protocol are not available to us, the tests may be repeated. If your clinical condition warrants follow up at NCI, we will repeat these tests based on clinical needs. In addition, we will obtain the following samples for future research purposes: About 12 teaspoons (60 ml) of blood Slightly less than ¼ cup of urine These samples will be obtained only once during the study unless your clinical condition warrants follow up at NCI, in which case we will obtain these samples once a year. The following may be collected either when your clinical condition requires it or when another NCI protocol requires it. Samples will be stored for future research. Abnormal fluid - People with cancer sometimes develop fluid collections in parts of the body that contain cancer cells, such around the lungs or in the abdomen. If you have such a fluid collection that needs to be drained, we will ask for a sample of that abnormal fluid. This sampling will usually be done at the time that fluid is collected for diagnostic or treatment purposes. Fluid is collected by putting a needle with a syringe attached into the body cavity where the fluid is located. The risks associated with the drainage of abnormal fluids depend on the location of the fluid. If abnormal fluid needs to be drained, the physician or other individual performing the procedure will explain the risks.
4 CONTINUATION: page 4 of 13 pages The following may be collected at a single time point while you are enrolled on this study, or if you are enrolled on an NCI treatment protocol, before you begin treatment on that protocol and any time the treatment protocol requires it. Tumor biopsy (optional if collected only for this study) A biopsy is a procedure using a needle to remove a piece of tissue or a sample of cells from your body so that it can be analyzed in a laboratory and is used to diagnose or evaluate the cancer. We will use a portion of the biopsy samples to determine the mesothelin level in your tumor. The rest will be stored for future studies. You will be given the opportunity below to decide whether you want to have this sample collected. What tests may be performed on the samples that are stored? Your stored samples may at a later date be examined under an electron microscope, may be stained so that certain properties of cells are visible under a microscope, or may be used to conduct other laboratory studies of the molecules inside of your cells We may also conduct genetic studies of your tumor tissue and your normal tissue to look for differences in DNA between tumor and normal tissue, or differences in how people with certain DNA changes in tumor or normal tissue are different from each other with regard to how cancer develops and how it responds to treatment. DNA (also called deoxyribonucleic acid) are the molecules inside cells that carry genetic information and pass it from one generation of cells to the next like an instruction manual. Normal tissue contains the DNA (instructions) that you were born with, DNA in tumor cells has changed or mutated and we think that change in the DNA is what causes tumors to form and to grow. In order to determine which parts of the DNA have mutated, we will compare the DNA in your tumor cells to DNA from your normal cells. We will then analyze all of the results from similar tumors to see if there are any changes in the DNA that are common to a particular type of tumor. In order to examine the tumor and normal tissue we may use several different techniques depending on the type of tissue we collect. These could include growing cell lines (cells which keep dividing and growing in the laboratory, sometimes for years allowing us to continually study those cells) and looking in great detail at the parts of the genes that produce specific proteins. When we are examining these pieces of your DNA, it is possible that we could identify possible changes in other parts of your DNA that are not related to this research. These are known as incidental medical findings. These include: Changes in genes that are related to diseases other than cancer Changes in genes that are not known to cause any disease. These are known as normal variations. Changes in genes that are new and of uncertain clinical importance. This means that we do not know if they could cause or contribute to a disease or if they are normal variations.
5 CONTINUATION: page 5 of 13 pages However, the analyses that we perform in our laboratory are for research purposes only; they are not nearly as sensitive as the tests that are performed in a laboratory that is certified to perform genetic testing. Changes that we observe unrelated to our research may or may not be valid. Therefore, we do not plan to inform you of the results of testing on your tissue and blood that is performed in our research lab. However, in the unlikely event that we discover a finding that is believed to be clinically important based on medical standards at the time we first analyze your results, we will, if you agree, contact you so that results may be confirmed in a clinical laboratory. This could be many years in the future. If you want this to be done, we will draw an additional blood sample and send it for confirmatory testing. Once the results are available, if you would like to receive your results we will offer to have you come to NIH (at our expense) to have genetic education and counseling to explain this result. If you do not want to come to NIH, we will help you find a local genetic healthcare provider who can explain it to you (at your expense). Please note that if you are signing for a minor child, the child will be contacted after they have reached the age of 18 so that they can decide whether they would like to continue in the study. At this time, they will be able to choose whether or not they would like to be contacted with clinically relevant findings. If the incidental findings are discovered before the child has reached the age of 18, we will contact you if you have indicated that as your preference below. _[ ] I DO NOT want to be recontacted if incidental findings with potential health implications are discovered. _[ ] I DO want to be recontacted if incidental findings with potential health implications are discovered. (You will be given a choice to learn or not learn about a genetic change that we find.) It is possible that none of the studies described above in this section will be performed. Note: In order for us to contact you about genetic variants as described above, you must remain on the study even after all samples have been collected so that we may maintain your up to date contact information and contact you at the time findings are discovered. Who else besides the investigators on this study will know the results of your sample testing? Once we obtain any of the samples listed above, the investigators take all your personal information off those samples and label them with a study code number. Only the investigators on this study know who the sample came from. The key linking your personal information with the code number is kept in a secure computer data base, with access only to the 2-3 research staff who will be discussing this study with you. Once the sample has been labeled with a code, it is sent to a variety of NIH laboratories for storage and testing. No one testing your samples will be
6 CONTINUATION: page 6 of 13 pages able to link the results to you personally. Specimens obtained during your participation in this study may be sent for testing to investigators outside of NCI or the NIH. All samples will be coded to protect your privacy and no personal information will be included. Other investigators on this study will have access to limited clinical and biologic data such as age, gender and disease status. Your individual genomic data and health information will be put in a controlled-access database. This means that only researchers who apply for and get permission to use the information for a specific research project will be able to access the information. Your genomic data and health information will not be labeled with your name or other information that could be used to identify you. Researchers approved to access information in the database have agreed not to attempt to identify you. Such databases may be useful beyond the aims of this particular study, especially as various diseases turn out to have mechanisms in common. The value of these data can increase when they are shared with the broader research community. While no traditionally identifying information will be shared, it is possible that you or a family member may be identified as outlined below in the section on the release of genetic information. How long will your samples be stored? The samples collected during this study will be stored for as long as the study is open. When this study is closed, we would like to keep the samples for future research. We will request your permission to do so, later in this consent. Long term follow-up While you are enrolled on this study, we would like to call you once a year to find out how you are doing. We would like to call you whether or not you we are still seeing you in the clinic. Alternative Approaches or Treatments You may not participate in this research. As no treatment is provided on this study, your refusal to participate or your participation will not affect your treatment in any way. Risks or Discomforts of Participation Risks Associated with Sampling Only small amounts of additional blood, tumor, urine and abnormal fluid will be collected at a time that you are scheduled for sampling required for your care. The amount of blood and/or tumor collected will be limited according to NIH safety standards. Thus, there should be minimal risk to you from participation in this study.
7 CONTINUATION: page 7 of 13 pages Blood Drawing: Side effects of blood draws include pain and bruising in the area where the needle was placed, lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood cell count (anemia) can develop. Urine Collection: There are no physical risks or discomforts associated with urine collection Tumor samples (biopsy): This procedure usually causes only brief discomfort at the site from which the biopsy is taken. Rarely, infection or bleeding may occur at the needle site. Psychological or Social Risks Associated with Loss of Privacy The following general points are indirectly related to your participation in the research study. 1. Unanticipated medical information: During the course of this investigation, it is possible (although not likely) that we will obtain unanticipated information about your health or genetic background. 2. Release of genetic information: Your privacy is very important to us and we will use many safety measures to protect your privacy. However, in spite of all of the safety measures that we will use, we cannot guarantee that your identity will never become known. Although your genetic information is unique to you, you do share some genetic information with your children, parents, brothers, sisters, and other blood relatives. Consequently, it may be possible that genetic information from them could be used to help identify you. Similarly, it may be possible that genetic information from you could be used to help identify them. While the controlled-access databases developed for this project will not contain information that is traditionally used to identify you, such as your name, address, telephone number, or social security number, people may develop ways in the future that would allow someone to link your genetic or medical information in our databases back to you. For example, someone could compare information in our databases with information from you (or a blood relative) in another database and be able to identify you (or your blood relative). It also is possible that there could be violations to the security of the computer systems used to store the codes linking your genetic and medical information to you. Since some genetic variations can help to predict the future health problems of you and your relatives, this information might be of interest to health providers, life insurance companies, and others. Patterns of genetic variation also can be used by law enforcement agencies to identify a person or his/her blood relatives. Therefore, your genetic information potentially could be used in ways that could cause you or your family distress, such as by revealing that you (or a blood relative) carry a genetic disease. There also may be other privacy risks that we have not foreseen.
8 CONTINUATION: page 8 of 13 pages Since some genetic variations can help to predict future health problems for you and your relatives, this information might be of interest to health care providers, life insurance companies, and others. However, Federal and State laws provide some protections against discrimination based on genetic information. For example, the Genetic Information Nondiscrimination Act (GINA) makes it illegal for health insurance companies, group health plans, and most employers to discriminate against you based on your genetic information. However, GINA does not prevent companies that sell life insurance, disability insurance, or long-term care insurance from using genetic information as a reason to deny coverage or set premiums. GINA also does not apply to members of the United States military, individuals covered by the Indian Health Service, or veterans obtaining health care through the Veteran s Administration. Lastly, GINA does not forbid insurance medical underwriting based on your current health status though the Affordable Care Act limits consideration of pre-existing conditions by insurers. Potential Benefits of Participation There are no direct benefits to you from participation in this study. The planned research studies are believed to have no direct clinical value to you or your family members now or in the future. No results of the research studies performed on this protocol will be provided to you or your medical care team; however, information from any of the genetic testing that we may conduct may be disclosed to if it has health implications if you asked us to do so above. Your participation may help us advance the understanding of mesothelioma and to develop new treatments for these cancers in the future. Research Subject s Rights What are the costs of taking part in this study? If you choose to take part in the study, the following will apply, in keeping with the NIH policy: There is no charge for participating in this study. You will not be paid to participate in this study; and It is possible that the information obtained from your participation on this study may become valuable for commercial research and development purposes (including patentable inventions), which may be of significant benefit to society, individual researchers, or other third parties. You will not receive direct financial benefit from such research and development.
9 Will your medical information be kept private? CONTINUATION: page 9 of 13 pages We will do our best to make sure that the personal information in your medical record will be kept private. However, we cannot guarantee total privacy. Organizations that may look at and/or copy your medical records for research, quality assurance, and data analysis include: The National Cancer Institute (NCI) and other government agencies, which are involved in keeping research safe for people. National Cancer Institute Institutional Review Board Stopping Study Participation Participation in this study is voluntary. You may leave the study at any time. You will be given a copy of the consent form for your records. There are no penalties for leaving the study. If you choose not to participate in this study, or if you participate in this study but choose not to have certain samples collected, this will not affect your care or your ability to participate in other clinical trials at the NIH. If you leave the study, any remaining samples of yours that have been obtained for the study can be destroyed. However, the samples and data generated from the samples that have already been distributed to other researchers or placed in the research databases cannot be withdrawn. You may ask our staff to answer any and all questions and we invite you to do so. Any new findings that relate to your participation will be discussed with you. Your doctor may decide to stop your participation if he/she believes that it is in your best interest. In any case, you will be informed of the reason that you are being taken off this protocol. You can stop taking part in the study at any time. However, if you decide to stop taking part in the study, we would like you to talk to the study doctor first. Certificate of Confidentiality We have obtained a Certificate of Confidentiality from the Department of Health and Human Services. The Certificate is designed to prevent us from being forced to disclose identifying information for use in any federal, state, or local civil, criminal, administrative, legislative, or other court proceeding, even if faced with a court subpoena. You should understand, however, that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about yourself or your involvement in this research. We may not withhold information if you give your insurer or employer or a law enforcement agency permission to receive information about your participation in this project. This means that you and your family must also actively protect your own privacy.
10 CONTINUATION: page 10 of 13 pages The Certificate does not prevent us from taking steps, including reporting to authorities, to prevent serious harm to yourself or others. We will also share information as described in item 1 on page 12. Optional Biopsy The biopsy to be performed is exclusively for research purposes and will not benefit you. It might help other people in the future. Even if you sign "yes" to have the research tests you can change your mind at any time. Please read the sentence below and think about your choice. After reading the sentence, circle and initial the answer that is right for you. The decision to participate in this part of the research is optional, and no matter what you decide to do, it will not affect your care. I agree to have the tumor biopsy for the research tests in this study. Yes No Initials Optional Studies We would like to keep some of the specimens and data that are collected for future research. These specimens and data will be identified by a number and not your name. The use of your specimens and data will be for research purposes only and will not benefit you. It is also possible that the stored specimens and data may never be used. Results of research done on your specimens and data will not be available to you or your doctor. It might help people who have cancer and other diseases in the future. If you decide now that your specimens and data can be kept for research, you can change your mind at any time. Just contact us and let us know that you do not want us to use your specimens and/or data. Then any specimens that remain will be destroyed and your data will not be used for future research. Please read each sentence below and think about your choice. After reading each sentence, circle and initial the answer that is right for you. No matter what you decide to do, it will not affect your care. 1. My specimens and data may be kept for use in research to learn about, prevent, or treat cancer or other health problems. Yes No Initials
11 CONTINUATION: page 11 of 13 pages 2. Someone may contact me in the future to ask permission to use my specimens and/or data in new research not included in this consent. Yes No Initials
12 CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Adult Patient or Parent, for Minor Patient CONTINUATION: page 12 of 13 pages OTHER PERTINENT INFORMATION 1. Confidentiality. When results of an NIH research study are reported in medical journals or at scientific meetings, the people who take part are not named and identified. In most cases, the NIH will not release any information about your research involvement without your written permission. However, if you sign a release of information form, for example, for an insurance company, the NIH will give the insurance company information from your medical record. This information might affect (either favorably or unfavorably) the willingness of the insurance company to sell you insurance. The Federal Privacy Act protects the confidentiality of your NIH medical records. However, you should know that the Act allows release of some information from your medical record without your permission, for example, if it is required by the Food and Drug Administration (FDA), members of Congress, law enforcement officials, or authorized hospital accreditation organizations. 2. Policy Regarding Research-Related Injuries. The Clinical Center will provide shortterm medical care for any injury resulting from your participation in research here. In general, no long-term medical care or financial compensation for research-related injuries will be provided by the National Institutes of Health, the Clinical Center, or the Federal Government. However, you have the right to pursue legal remedy if you believe that your injury justifies such action. 3. Payments. The amount of payment to research volunteers is guided by the National Institutes of Health policies. In general, patients are not paid for taking part in research studies at the National Institutes of Health. Reimbursement of travel and subsistence will be offered consistent with NIH guidelines. 4. Problems or Questions. If you have any problems or questions about this study, or about your rights as a research participant, or about any research-related injury, contact the Principal Investigator, Raffit Hassan, M.D., Building 10, Room 10-CRC/4-5330, Telephone: You may also call the Clinical Center Patient Representative at If you have any questions about the use of your specimens or data for future research studies, you may also contact the Office of the Clinical Director, Telephone: Consent Document. Please keep a copy of this document in case you want to read it again. CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY (Continuation Sheet) Adult Patient or Parent, for Minor Patient
13 CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Adult Patient or Parent, for Minor Patient CONTINUATION: page 13 of 13 pages COMPLETE APPROPRIATE ITEM(S) BELOW: A. Adult Patient s Consent B. Parent s Permission for Minor Patient. I have read the explanation about this study I have read the explanation about this study and have been given the opportunity to discuss and have been given the opportunity to discuss it and to ask questions. I hereby consent to it and to ask questions. I hereby give take part in this study. permission for my child to take part in this study. (Attach NIH , Minor s Assent, if applicable.) Signature of Adult Patient/ Legal Representative Date Signature of Parent(s)/ Guardian Date Print Name Print Name C. Child s Verbal Assent (If Applicable) The information in the above consent was described to my child and my child agrees to participate in the study. Signature of Parent(s)/Guardian Date Print Name THIS CONSENT DOCUMENT HAS BEEN APPROVED FOR USE FROM MAY 4, 2015 THROUGH MAY 3, Signature of Investigator Date Signature of Witness Date Print Name Print Name CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY (Continuation Sheet) Adult Patient or Parent, for Minor Patient
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UNIVERSITY OF MICHIGAN CONSENT TO BE PART OF A RESEARCH STUDY INFORMATION ABOUT THIS FORM You may be eligible to take part in a research study. This form gives you important information about the study.
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA) THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
Nova Southeastern University IRB - Consent Form Checklist Version Date: 02/17/2010 This form is intended to assist researchers in creating consent and assent forms. Informed consent is one of the primary
HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
NOTICE OF PRIVACY PRACTICES The University of North Carolina at Chapel Hill UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
LAKELAND FAMILY MEDICINE Dennis J. Charette, M.D. 155 McDonald Drive SW Shirley E. Charette, MS, PA-C Carri A. Meiler, MS, PA-C Phone: 330-308-8999 Fax: 330-308-8016 www.lakelandfamilymedicine.com PATIENT
Wyoming School Boards Association Insurance Trust ( The Plan ) HEALTH CARE PLAN PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
UNIVERSITY OF MICHIGAN CONSENT TO BE PART OF A RESEARCH STUDY Do not place anything in the header at the top of the page. The information will be completed when the IRBMED approves the document in eresearch.
Impact of Breast Cancer Genetic Testing on Insurance Issues Prepared by the Health Research Unit September 1999 Introduction The discoveries of BRCA1 and BRCA2, two cancer-susceptibility genes, raise serious
Patient Support Guide to genetic testing for hereditary breast and ovarian cancer syndrome Testing for BRCA1 and BRCA2 is available from Quest Diagnostics. Quest Diagnostics Patient Support Guide to Genetic
Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
National Emphysema Treatment Trial (NETT) Consent for Screening and Patient Registry Instructions: This consent statement is to be signed and dated by the patient in the presence of a certified study staff
Notice of Privacy Practices KAISER PERMANENTE NORTHERN CALIFORNIA REGION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY (PEBA) NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised September 23, 2013 This notice describes how medical information about you may be used
Clinical Trials Helpful information and answers for patients I joined a clinical trial because I want to make it a better world for my daughter and grandchildren. Hopefully, by the time they re old enough
MEDICAL BENEFITS CLASS ACTION SETTLEMENT NOTICE OF INTENT TO SUE Complete this form if you are a MEDICAL BENEFITS SETTLEMENT CLASS MEMBER seeking to exercise a BACK END LITIGATION OPTION. In addition to
HIPAA Notice of Patient Privacy Practices Effective Date: January 1, 2014 THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Research Involving Human Biological Materials: Ethical Issues and Policy Guidance Executive Summary Introduction Biomedical researchers have long studied human biological materials such as cells collected
Substance Abuse Program www.tridentinsurance.net Lines of Business: Auto, Worker Compensation, Public Officials Liability, Educators Legal Liability, General Liability Risk Control Strategy/Key Issues:
NOTICE OF PRIVACY PRACTICES FOR OUR PATIENTS POTOMAC PHYSICIAN ASSOCIATES, P.C. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Page 1 of 6 The University of Texas Southwestern Medical Center at Dallas CONSENT TO PARTICIPATE IN RESEARCH Short Screening Consent Title of Research: Physical and Metabolic Abnormalities in Lipodystrophy
The Health and Benefit Trust Fund of the International Union of Operating Section 1: Purpose of This Notice Notice of Privacy Practices Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL
JOHNS HOPKINS NOTICE OF PRIVACY PRACTICES FOR HOPKINS ELDERPLUS/PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Effective Date: September 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
Compliance Document for Holland Public Schools, G-768 Employers sponsoring a group health plan are required by law to provide certain notices to individuals within a set time frame. ASR Health Benefits
GLOUCESTER COUNTY PUBLIC SCHOOLS EMPLOYEE HEALTH CARE PLAN, GLOUCESTER COUNTY PUBLIC SCHOOLS EMPLOYEE DENTAL CARE PLAN, GLOUCESTER COUNTY PUBLIC SCHOOLS EMPLOYEE FLEXIBLE BENEFITS PLAN 1 NOTICE OF PRIVACY
Shawnee Mission Medical Center HIPAA NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Date: June 1, 2014 Salt Lake Community College
APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults
1. What is the prostate-specific antigen (PSA) test? Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor