OMB #: 0935-0104 PANEL 9

OMB #: 0935-0104 PANEL 9

AUTHORIZATION TO OBTAIN INFORMATION FROM PHARMACIES AND PHARMACY RECORDS
MEDICAL EXPENDITURE PANEL SURVEY - U.S. PUBLIC HEALTH SERVICE

A.	Provider Name: Street Address: City: State: Zip: Telephone: (________) ________ - __________ Area Code

I am voluntarily participating in the Medical Expenditure Panel Survey (MEPS), a study of health care use and expenses being conducted by the U.S. Public Health Service. I authorize and request that you provide the U.S. Public Health Service and its contractors with the medical and financial information they request about prescriptions filled or refilled for my use during the period January 1, 2004 to December 31, 2005. This authorization form applies to any and all prescribed medicines received by me during this period.

I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA)⁽¹⁾ prohibits you from releasing my information without my authorization. This form (or a photocopy of this form) gives you my authorization. I have signed this form voluntarily, with the understanding that my decision to sign or not to sign the form will have no effect on my eligibility for treatment, payment, enrollment, or eligibility for any benefits to which I am entitled.

I understand that the Public Health Service and its contractors will use this information to supplement the information I have already given for MEPS research on health care use and expenditures. I also understand that once my information is released to the study, it is no longer covered by HIPAA but is covered by the Public Health Service Act⁽²⁾, which prohibits the release of information that would identify me, my medical providers, or my pharmacies outside the sponsoring agency and its contractors without my permission or that of my medical providers and pharmacies.

I authorize the study to use information I have given in the survey to help you identify my records. I also understand that I can revoke this authorization at any time by contacting a study representative in writing or by telephone. Otherwise, this authorization expires 30 months from the date of signature.

C.	1. Patient Name:
	2. Date of Birth _____ / _____ / ______ Month Day Year
	3. Other Names Under Which Records May be Filed
	3A. Social Security Number⁽³⁾ _____ - ____ - ______

D.	4. _________________________________________________ Patient’s Signature - 14 and over sign
	5. Date Signed
	IF PATIENT IS 14-17, BOTH PATIENT AND PARENT/GUARDIAN MUST SIGN AND DATE.

E.	6. _________________________________________________ Parent, Guardian, Witness or Proxy’s Signature
	7. Date Signed
	8. _________________________________________________ Signer’s Relationship to Patient
	9. Reason for Parent, Guardian, Witness or Proxy’s Signature:
	□ Patient 13 or Younger Patient Disabled
	□ Patient 14-17 Years Old Patient Deceased

FIELD USE ONLY:

RU ID: ____________________________

PROVID: __________________________

PID: ______________________________

(1)			Health Insurance Portability and Accountability Act: 42 U.S.C. 1320d-2 and 1320d-4 and the implementing regulation, 45 CFR 164.508, require a detailed authorization for your health care provider to disclose health information from your records for research purposes.
(2)			Public Health Service (PHS) Act: Sections 924(c) and 308(d) [42 U.S.C. 299c-3(c), and 42 U.S.C. 242m(d)] protect the confidentiality of data collected under the research authorities of the Agency for Healthcare Research and Quality and the National Center for Health Statistics in the U.S. Public Health Service. Section 543 of the PHS Act [42 U.S.C. 290dd-2,] and regulations at 42 CFR Part 2, provide additional confidentiality restrictions on records of alcohol and substance abuse patients. This research project will be carried out in compliance with all these provisions.
(3)			Your Social Security Number is requested to allow the addressee to accurately identify and help locate your records. Providing this information is voluntary. It is collected under the authority of Title IX of the Public Health Service Act Section 902(a) (42 USC 299a). Refusal to provide the number will have no effect on your rights, benefits or privileges under law.

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CODE

SCAN: □ Yes □ No

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FIID