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*** See www.compliance.wisc.edu/hipaa for up-to-date content. ***

The UW-Madison HIPAA Compliance Program is updating policies, forms, FAQs, and guidelines to better serve your needs.  Additionally -- we are migrating content from these pages to www.compliance.wisc.edu/hipaa; once we complete the migration, this site will retire and visitors to these pages will be re-directed to that location.  Thank you in advance for your patience! 

Please forward your website improvement suggestions to hipaa@wisc.edu.   


 

 

Accounting of Disclosures

Accounting of Disclosures Log:  this log must be used to record all disclosures of research subjects' protected health information which occur based on an IRB waiver of authorization.

Authorizations for Use or Disclosure of PHI in Research
Please note, these are templates only.  As with your research consent form, your HIPAA authorization form will need to be tailored to fit the particular uses and disclosures of PHI in your study.

Research Authorization

Research Authorization for Children

Research Authorization Wizard (not for interventional studies)

Combined Research Consent and Research Authorization Wizard (not for interventional studies)

Research Authorization -- Veterans Affairs (VA)

Certifications

Certification for Activities Preparatory to Research:  this certification must be signed prior to using PHI in the preparation of a research protocol.

Certification for Research on the Protected Health Information of Decedents:  this certification must be signed when the research, or a distinct part of the research, uses only the protected health information of decedents. 

Certification for Disclosure of a Limited Data Set from the UW-Madison Health Care Component:  this certification must be signed when a UW-Madison employee outside of the health care component receives a limited data set from within the health care component.

Certification for Use of a Limited Data Set Within the UW HCC or UW ACE:  this certification must be signed when an employee within the health care component or within the affiliated covered entity receives a limited data from the the same.

Database Forms and Tools

Database Decision Tool:  this tool is used to determine if a database that is used for research purposes must be registered with the UW-Madison HIPAA Privacy Officer.

Database Registration and Preparatory to Research Certification for Database Custodian:  this form is used to register a database with the UW-Madison Privacy Officer and, when applicable, for the database custodian to certify use of the database in preparation of a research protocol.

Data Use Agreement and Related Forms

Data Use Agreement:  this agreement must be completed before receiving or disclosing a limited data set.

Data Use Agreement Evaluation Form:  this form is used to evaluate another covered entity's data use agreement when UW-Madison is the recipient of a limited data set.