Records - Stargardt-type Disease Clinical Study

Your information

Full Legal Name used on Medical Records required

As it appears on your medical records — not a nickname.

Previous Name(s) used on Medical Records

Date of Birth required

Your ZIP Code required

Email required

Used to deliver your signed copy.

Phone

Request for Release of Information

I authorize any healthcare provider, hospital, clinic, pharmacy, health plan, health information exchange, or health information network that holds my medical records to disclose them as described below. (You may also identify a specific provider or facility below, but disclosure is not limited to that provider.)

Healthcare Provider or Facility required

The doctor or clinic we should request your records from — for example, your neurologist or primary care provider.

Provider / Facility Address required

Street address if you know it — at minimum the city and state.

I release my medical records to: Clinical Enrollment, Inc.

Clinical Enrollment, Inc., 105 Monticello Ave, Unit 100, Charlottesville, VA 22902

Medical records to be disclosed check all that apply

All of my medical records from the two (2) years prior to the date of my signature on this document, except as protected by law. All of my medical records that the provider has in their possession, except as protected by law. All of my medical records that the provider has in their possession, INCLUDING the following: ONLY my medical records relating to the following:

Highly sensitive information

I authorize disclosure of the following categories of highly sensitive information. Mark Yes or No for each. If a category is left blank, it will NOT be disclosed.

Purpose of this authorization

I am being screened by Clinical Enrollment, Inc. (“Clinical Enrollment”) for possible participation in one or more clinical research studies. I authorize the release of my medical records to Clinical Enrollment so that it may verify my information and determine my eligibility for, and facilitate my enrollment in, the clinical research study or studies for which I am being screened.

Re-disclosure

Information disclosed under this authorization may be re-disclosed by Clinical Enrollment to clinical research sites and study personnel for the purpose of screening and enrollment. Once re-disclosed, information may no longer be protected by federal or state privacy law. Clinical Enrollment will limit its use and disclosure of my information to the purposes described in this authorization.

Term

This authorization will remain effective for two (2) years from the date of my signature, unless I revoke it sooner.

Refusal to sign / revocation

I understand I may refuse to sign this authorization for any reason, and that such refusal will not affect the commencement, continuation, or quality of my provider's treatment of me, or my eligibility for health benefits. I may revoke this authorization at any time by writing to Clinical Enrollment, Inc., Attn: Operations Team, 105 Monticello Ave, Unit 100, Charlottesville, VA 22902, or by email to records@clinicalenrollment.com. Revocation is effective upon receipt, except to the extent that Clinical Enrollment or others have already relied on this authorization. I understand that records already obtained before my revocation may continue to be used and shared as necessary to maintain the integrity of a research study in which I have enrolled and as otherwise required by law.

Limits on sensitive records

Except to the extent I have specifically authorized in the Highly Sensitive Information section above, this authorization does not extend to psychotherapy notes, to substance-use-disorder treatment records protected by 42 C.F.R. Part 2, or to other categories of information that require separate authorization under applicable state or federal law.

My rights

I have the right to request and receive a copy of this authorization by contacting the Operations Team at the address above or at help@clinicalenrollment.com.

I am at least 18 years of age. If the individual is unable to sign, an authorized guardian or representative may complete the guardian block below.

Who is signing?

I am signing for myself I am a guardian / representative signing for the individual

Electronic signature consent (E-SIGN)

I agree that my electronic signature is the legal equivalent of my handwritten signature and consent to conduct this transaction electronically under the E-SIGN Act and applicable state law. I confirm that I am able to access, and to retain a copy of, this authorization in electronic form. required

Optional — your choice

Keep getting matched to studies that fit you

Finding the right clinical study can take time. If you'd like, we can hold onto a short summary of your health information and keep an eye out for other studies you may qualify for — so the next time there's a good fit, we already know to reach out to you.

If you opt in, here's what that means:

We keep a brief summary of key details from your records (things like your diagnoses, medications, and relevant lab results).
We periodically check whether new studies might be a fit for you.
If we find one, we reach out to you about it — and we only share your records with a study site after you say yes again.

This is completely your choice. You don't need to opt in to take part in the study you're here for, and your decision won't affect your care or your screening in any way. You can change your mind and opt out anytime by emailing records@clinicalenrollment.com. We'll keep your summary for up to six years (we'll check in before then), and if you opt out we'll delete what we're still holding, except where the law requires us to keep it.

Yes — keep me matched to future studies. I've read the above and I'm opting in.

No check, no signature? No problem — you're simply not opted in, and only the authorization above applies.

Authorization for the Retrieval of Medical Records