1. I understand that I am going to be asked certain questions regarding my personal medical condition by TrialTech Medical, Inc. (“TrialTech”) personnel so they can determine if I might be a suitable candidate for a clinical research study. Initially, I will complete a questionnaire requesting limited information so that an initial evaluation may be made. TrialTech is assisting in the recruitment of suitable candidates for the RePRIEVE-CM clinical research study.
2. Subject to the results of the initial evaluation, I may be referred for a telephone consultation with a TrialTech health care professional who will ask me additional information about my medical condition, general health and medical history. If the health care professional believes that I might be a suitable candidate for the RePRIEVE-CM clinical research study, he or she may use my information to refer me for the purposes of further evaluation to an investigator who is conducting the RELIVE-HF clinical research study at a hospital site or sites nearest to me.
3. I agree to allow TrialTech and its personnel and associates, including the health care professional, to receive the personal information that I am providing and to disclose it to the clinical research study investigator to evaluate my medical condition solely for determining whether I may potentially qualify to participate in the RePRIEVE-CM clinical research study.
4. I understand that it is not guaranteed that I will be determined to be eligible or that I will be accepted to participate in the RePRIEVE-CM clinical research study. Only the clinical investigator can ultimately determine my eligibility.
5. If accepted as a participant in the clinical research study, the clinical investigator will fully inform me about the study, its procedures and risks and will ask me to sign an Informed Consent Form. I understand that my consent contained in this Authorization is not intended to take the place of the Informed Consent Form which I will be asked to sign if I am to become a participant in the RePRIEVE-CM clinical research study.
6. Except as allowed by me pursuant to this Authorization, TrialTech will not use, disclose or sell my personal information or disclose my identity to third parties. Although TrialTech is not a HIPAA covered entity, it has taken reasonable security measures (based on HIPAA requirements) including secure servers, private data services, software encryption and others to protect my personal information disclosed on this site. Notwithstanding, TrialTech disclaims all responsibility for the protection of my personal information by the clinical research study site or other persons or entities who may gain access to my information. There is a possibility that once disclosed to the clinical investigator, privacy laws may no longer protect my information from being given to another person, class of persons, and/or companies.
7. I understand that once information that could be used to identify me has been removed and my information is no longer personally identifiable (i.e. connected to my identity), the anonymized information may be aggregated with anonymized information of others and used for research or business purposes.
8. No publication or presentation of my personal information will reveal my identity without my separate specific written permission and authorization.
9. I understand that I have the right to decline approval of this Authorization. If I refuse, TrialTech will not accept submission of my personal information and I will not be able to be evaluated for the RePRIEVE-CM clinical research study by TrialTech. I understand that subject to review of this questionnaire and my Authorization, I may be contacted by TrialTech personnel to schedule a telephonic interview.
10. I understand that I may change my mind and cancel this Authorization prior to the time that my evaluation by TrialTech is complete. To cancel this Authorization, I must send an email to TrialTech at email@example.com
stating that I wish to cancel. I have been advised to print a copy of this Authorization for my records. This Authorization has no expiration date.