PHI from an Institution without a Privacy Board

If PHI will be obtained from an institution that does not have a Privacy Board, please complete the appropriate form below:

If PHI will be obtained with written HIPAA authorization from individual subjects, please complete the BC Authorization Form

If PHI will be fully de-identified (include no HIPAA identifiers), please complete the HIPAA De-Identification Certification Form

If PHI will be a limited data set (include no HIPAA identifiers except dates such a birth date, admission and/or discharge date, treatment dates or geographic location excluding street address), please complete the Limited Data Set Agreement

If PHI will include information on decedents only, please complete the Application for Research on Decedents’ Information

If you are seeking a waiver of HIPAA authorization from the institution, please complete the Application for Waiver of Individual Authorization for Use or Disclosure of Protected Health Authorization