McLean Hospital by JXA949

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									                                   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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