Potential Patient Form

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Privacy Statement

Per the federal Health Insurance Portability and Accountability Act (HIPAA), all individually identifiable health information that is provided to Northwest Research Center (NWRC) in the course of submission, evaluation, assessment, and treatment is considered “Protected Health Information” (PHI). This information includes demographics and relates to your past, present, and future physical and/or mental health or condition and related health care services. NWRC will maintain all information in a confidential and secure manner, ensuring that only authorized personnel will have access to your PHI. Unless required by state or federal law, NWRC will not release or disclose your PHI without your prior written authorization. You are permitted to review and request copies of the PHI, as well as withdraw the authorization for NWRC’s use of the information, at any time. Your PHI will be used to evaluate your potential for participation in our clinical research studies. If you believe the information we have is incorrect or out of date, please contact us to provide updates and we will promptly address the problem. By submitting your information, you consent to be contacted by a member of our staff now or in the future.

I have read and acknowledge the Privacy Statement and consent to a member of Northwest Research staff contacting me now or in the future.