North Shore Long Island Jewish Health System

                         OPTIONAL Authorization for Research Contact
Part of the mission of the North Shore-Long Island Jewish Health System is to advance medicine
through biomedical research. By signing below you are giving permission for your doctors to release
your name, diagnosis, and contact information to the following researcher/department at NSLIJHS for
the purpose of contact for future research studies.

         Investigator Name/Department:_________________________________________________

         NSLIJHS Facility: ___________________________________________________________

If you agree, your diagnosis and the following information will be shared with researchers. Please
complete the following:
        Patient Name: ________________________________________________________________________________

        Address: ____________________________________________________________________________________

        Date of Birth: _________________________ Telephone Number: ______________________________________

If you sign this form, a researcher may contact you about joining a research study. If you are asked to
be in a study, you will be asked to sign an informed consent for research form.

Your information will not be given to anyone else outside the research team. The permission to share
your contact information will be in effect for 1 year from the date of your signature or until you revoke
this authorization. You do NOT have to sign this form. Your health care, the payment for your health
care, and your health care benefits will not be affected if you do not sign this form. If you have any
questions, please contact the Research Privacy Officer at (516) 562-2018.

If you sign this authorization, you will have the right to change your mind at any time, except to the
extent that the hospital has already taken action based upon your authorization. To revoke this
authorization, please write to:

Your Physician: ________________________________               or   Research Privacy Officer
Address:        ________________________________                    Office of Research Compliance
                ________________________________                    The Feinstein Institute for Medical Research
                ________________________________                    350 Community Drive 4th Floor
                ________________________________                    Manhasset, NY 11030

By signing below, you acknowledge that you have read and accept all of the above.

__________________________________________                          _________________________________
Signature of Patient or Legally Authorized Representative (LAR)     Date

__________________________________________                          ___________________________________________
Print Name of Patient or LAR (parent, guardian or individual        LAR’s Relationship to Patient
authorized to consent to the use of information)

The patient or his/her LAR must be provided with a copy of this form after it has been signed.
Please retain a copy in the patient’s records at the physician’s office and in the study’s critical documents
at the researcher’s office.
Revised 06.01.06
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