Prurigo Nodularis Study
If you would like additional information about this study, or to schedule an appointment to see if you qualify, please call our office at 586-286-7325. You may also fill out the Clinical Trial Request Form on this page, and we’ll make sure to reach out to you as soon as possible.
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HIPAA AUTHORIZATION. To the extent information in this form is protected health information under the Health Insurance Portability and Accountability Act, as amended, and its regulations (“HIPAA”), I authorize the use and disclosure of such information in accordance with this HIPAA AUTHORIZATION. I authorize the use and disclosure of all of the information that I have entered into this form (“Information”). I am the individual whose Information is included in this form or I am the personal representative of that individual. The purpose of this disclosure is to allow communication of the Information to a the medical practice from whose website I obtained this form. The Information will be disclosed to Dermatologists Of Central States and/or its information technology contractors (“Recipients”) in order to facilitate communication between me and the medical practice. I understand that I have the right to revoke this Authorization at any time prior to my submission of this form by simply not signing this Authorization, but once I sign this Authorization and submit the form, the Information will be disclosed to Recipients in reliance upon my Authorization. I understand that I am not required to sign this Authorization and that any medical practice making this form available on its website may not condition my treatment on whether I use this form to communicate with the medical practice. This Authorization has no expiration date. I understand that the Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipients and will no longer be protected by HIPAA. I hereby acknowledge that I may print a copy of this Authorization for my records.
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