McLean Hospital Acknowledgement of Receipt of Privacy Notice Research Subjects Federal law requires that all patients/research subjects be given a copy of the Privacy Notice. The Privacy Notice describes in detail how patient health information is used and shared with others. The Principal Investigator or a research staff member will give you a current copy of the Privacy Notice. All reasonable efforts will be made to protect the privacy of patient health information, whether it is maintained on paper or electronically, and regardless of how it is communicated, for example, by e-mail or facsimile mail. I have been given a copy of the Privacy Notice. Name (print):__________________________ Date:________________ Signature:______________________________ Date of Birth:_________ When a patient/subject is a minor, or is unable to give consent, the signature of a parent, guardian, or other representative is required. Signature of Representative:____________________________ Date:_____________ Name (print):_______________________ Relationship to Subject: _______________ Office Use Only Patient/subject given Privacy Notice, however: _____Patient/subject states they have signed Acknowledgement form previously. _____Patient refused or did not sign Acknowledgement form. _____Patient unable to sign Acknowledgement form. A copy of this should be in the subject’s medical/research record. Please return this form to the Research Privacy Office at McLean Hospital.
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