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Fillable Printable Authorization Withdrawal Letter

Fillable Printable Authorization Withdrawal Letter

Authorization Withdrawal Letter

Authorization Withdrawal Letter

Saint Louis University
Research Study Withdrawal & HIPAA Authorization Revocation Letter
PI Name
PI Address
PI Phone #
Study Title: _____________________________________________________________
Dear Dr. ____________,
I would like to withdraw my participation from the research study referenced above and
revoke my authorization to use and/or disclose my personal health information in
connection with my study participation. I am aware that health information already
collected will continue to be used and/or disclosed as described in the research consent
and authorization form, which I signed when enrolling into the study.
At this point, in addition to ending study participation, I would like to (please choose one
of the following options):
[ ] Withdraw from the study and revoke authorization
I revoke my authorization for the use and/or disclosure of my future health information.
(In rare instances, the research team may need to use your information even after you
revoke your authorization, for example, to notify you of any safety concerns.)
[ ] Withdraw from the study, but continue authorization
I allow the research team to continue collecting information from my medical records.
(This would be done only as needed to support the goals of the study and would not be
used for purposes other than those already discussed in the research consent and
authorization form.)
I understand that I will receive confirmation of this withdrawal letter.
______________________________________ ___________
Signature of Study Participant Date
______________________________________
Printed Name of Study Participant
Optional:
I am ending my participation in the above referenced study because:
________________________________________________________________________
Authorization withdrawal letter, February 2003 (RW)
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