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It explains the study’s purpose to share information about a unique medical problem, potential publication and conference presentation, and the categories of people and entities who may access records. It states that direct identifiers and images that identify the participant will not be included, while confidentiality cannot be fully guaranteed. It outlines participant choice, withdrawal requirements in writing, and signature blocks for patients, children, and legally authorized representatives.","INDIANA UNIVERSITY CONSENT AND AUTHORIZATION FOR CASE STUDY\nYou are being asked to allow use of your health information for a case study. The purpose of a case study is to share information about a unique medical problem to help other doctors and healthcare professionals. It is possible this case study may be published in medical journals and/or presented at conferences.\nWe are asking for your permission to use information [and images] related to your [specify disease, condition, or treatment]. The information about you released and used for this case study will include [insert description or bulleted list of record that will be accessed or used]\u0005. [Specify ALL individuals who will access information to prepare case study, e.g., Drs. XXX and YYY] who are preparing the case study may receive and/or use this information.\nIf you agree to participate, you authorize the following to disclose your medical record information:\n[list of entities from whom medical records will be obtained]\u0005\nThis information will be included in the case study along with demographic information, such as your age, sex, or race. Your name and other identifiers (e.g., date of birth, medical record number, etc.) and any images that directly identify you will not be included in the case study. Every effort will be made to keep your personal information confidential, but there is a risk of loss of confidentiality and/or privacy. We cannot guarantee absolute anonymity once the case study has been published or presented. It is possible that someone with knowledge of the unique circumstances surrounding your situation could identify you from the information and images included in the case study. Your personal information may be shared outside this case study if required by law and/or institutional policies, and these individuals or organizations may not be held to the same legal privacy standards as are doctors and hospitals.\nThere is no direct benefit to you for allowing us to use your information for this case study, but we hope that sharing this information will help others in the future.\nAfter reviewing this form and having your questions answered, you may decide to sign this form and allow your health information to be used for this case study. Or, you may choose not to allow your information to be used. This decision is up to you. If you choose not to allow your information to be used or change your mind after signing this document, it will not affect your usual medical care or treatment or relationship with [insert appropriate entity (i.e., hospital, university)].\nIf you change your mind and decide to withdraw your authorization for use and disclosure of your protected health information, you must do so in writing by notifying [name and mailing or email address]. However, once this case study has been published or presented, it will not be possible to withdraw your authorization. Otherwise, this authorization remains valid until the case study is published or presented.\nPATIENT’S CONSENT AND AUTHORIZATION\nIn consideration of all of the above, I agree to allow my health information to be used for this case study. I will be given a copy of this document to keep for my records.\nParticipant’s Printed Name:______________________________________________\nParticipant’s Signature:_________________________________________________Date:___________\nParticipant’s Address:__________________________________________________________________\n[FOR RESEARCH INVOLVING CHILDREN, USE THE FOLLOWNING SIGNATURE BLOCKS, AS APPLICABLE]\nPrinted Name of Child:___________________________________________________\nChild’s Address:_______________________________________________________________________\nPrinted Name of Parent:__________________________________________________\nSignature of Parent:_____________________________________________________Date:__________\n[If the child participant will NOT sign this document, REMOVE the child signature block below]\nPrinted Name of Child:________________","cbCaiqeEcbS8wx8D","https://ap.wps.com/l/cbCaiqeEcbS8wx8D","docx",33500,3,"English","en",105,"# Consent and Purpose\n## Permission to Use Health Information\n## Confidentiality and Privacy Risk\n# Participant Options and Withdrawal\n## No Benefit and Future Help\n## Decision and Impact on Care\n# Consent and Authorization Signatures\n## Patient Consent\n## Child Research Signature Blocks\n## Legally Authorized Representative Block","[{\"question\":\"What is the purpose of this case study consent form?\",\"answer\":\"The form authorizes use of health information to share details about a unique medical problem and help other doctors and healthcare professionals.\"},{\"question\":\"What information and images may be used in the case study?\",\"answer\":\"The study may use information and images related to the specified disease, condition, or treatment, including selected record descriptions listed in the form.\"},{\"question\":\"Will the participant’s identifying information be included?\",\"answer\":\"Direct identifiers and images that directly identify the participant will not be included; 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