HIPAA Authorization Form

We use Jotform, a secure and HIPAA-compliant platform, to collect your authorization and protect your privacy. This form allows us to securely request your medical records if needed.

If we need to review your medical records to confirm whether you’re eligible to come in for a screening visit — your first visit before joining a study — we may ask you to complete this HIPAA Authorization Form so we can securely request them from your doctor’s office.

If records aren’t needed in advance, you can also sign this form in person at your visit.