ࡱ> ,.+ Jbjbj$$ 4F|F|BTTTTThhh8 h#%%%%%%$nITITT^LTT## Ft0-T II@ : Saint Louis University Research Study Withdrawal & HIPAA Authorization Revocation Letter PI Name PI Address PI Phone # Study Title: _____________________________________________________________ Dear Dr. ____________, I would like to withdraw my participation from the research study referenced above and revoke my authorization to use and/or disclose my personal health information in connection with my study participation. I am aware that health information already collected will continue to be used and/or disclosed as described in the research consent and authorization form, which I signed when enrolling into the study. At this point, in addition to ending study participation, I would like to (please choose one of the following options): [ ] Withdraw from the study and revoke authorization I revoke my authorization for the use and/or disclosure of my future health information. (In rare instances, the research team may need to use your information even after you revoke your authorization, for example, to notify you of any safety concerns.) [ ] Withdraw from the study, but continue authorization I allow the research team to continue collecting information from my medical records. (This would be done only as needed to support the goals of the study and would not be used for purposes other than those already discussed in the research consent and authorization form.) I understand that I will receive confirmation of this withdrawal letter. ______________________________________ ___________ Signature of Study Participant Date ______________________________________ Printed Name of Study Participant Optional: I am ending my participation in the above referenced study because: ________________________________________________________________________     Authorization withdrawal letter, February 2003 (RW) Z ( - ` v w    FGIJ h|ECJ h|ECJjh|EUh|EB*ph h|E5\ h|E6]h|EB*phh|EZ[doz{z { * ( ) b v w ^h^h "#Jlmw    GHIJ2P/ =!"#0$% Dp^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH J@J  Heading 1$$@&a$5B*\phDA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List JC@J Body Text Indent ^6]4B@4  Body Text6]44 Header  !4 @"4 Footer  !@>@2@ Title$a$5B*CJ\phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] J AAADJ J 8@0(  B S  ?    HK    HK{#m    2<HK    K|E @J@Unknowng*Ax Times New RomanTimes New Roman5Symbol3. *Cx ArialA$BCambria Math"h7''7''   !0r0KQHX  $P 2!xx Authorization Withdrawal LetterSLU IRBEmily R. HarrisonOh+'0Tx    (4<DL Authorization Withdrawal LetterSLU IRBNormalEmily R. Harrison2Microsoft Office Word@@ @  ՜.+,0 hp  Saint Louis University   Authorization Withdrawal Letter Title  !"$%&'()*-Root Entry F/1Table WordDocument4SummaryInformation(DocumentSummaryInformation8#CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q