Decedent Research Attestation

Principal Investigators who need to access University of Texas Southwestern Medical Center (UT Southwestern) medical records or use protected health information (PHI) of individuals, who are deceased, for the purpose of research must submit this form to the Human Research Protection Program (IRB@UTSouthwestern.edu) for approval to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Study Title:
STU# (if applicable)
Name of Researcher:
Phone	Email
Department:
Date(s) Access/Use Will Occur:

List any Co-Investigators or coordinators for whom you are also requesting access:

Provide a brief description of PHI you will be using:

Assurance

I acknowledge that this certification applies to the use of protected health information (PHI) when my research protocol, or a distinct part of that protocol, is directed at decedents. I also acknowledge that the HIPAA Privacy Rule [45 CFR 164.512(i)(1)(iii)] imposes the following rules on my use of decedent’s PHI as described above.

The use and disclosure (if applicable) is sought is solely for research on the PHI of deceased individuals in the protocol named above.

At the request of an official of UT Southwestern Medical Center, I will provide documentation of the death of any individuals whose PHI I am seeking to use in the research protocol named above.

My use of the PHI of decedents is necessary for the purposes of carrying out the research protocol named above.

I will apply the rules written above to my research use of the PHI of decedents in accordance with the Health Information Portability and Accountability Act of 1996. I understand that any misrepresentation of the above information could result in criminal liability.

By signing this document, I certify that the above stipulations are correct

Investigator’s Signature: ________________________________________ ___ Date: ___ ___ __

Please retain a copy of this form for your records. The Principal Investigator will be responsible for maintaining the attestation for a minimum of 6 years from the date of creation.

Once approval is received, the Investigator is to follow the release of information process with Health Information Management to obtain decedent medical records.

Principal Investigators are referred to UT Southwestern Privacy Compliance Program Policy 7.24, Research on Decedents.

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