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{\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \qj \li0\ri0\sl-298\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\par 
\par [Letterhead]
\par }\pard \qj \li0\ri0\sl-288\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par 
\par [Date]
\par }\pard \ql \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par [Name] 
\par [Address 1] 
\par [Address 2]
\par }\pard \qj \li0\ri0\sl-298\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par Dear [Name]:
\par }\pard \ql \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par 
\par We are writing to you from the Clinical Trials Unit in the Department of XXX at 麻豆视频下载 about your interest in clinical research. In a previous conversation with us, you indicated that you wanted us to keep your name in our da
tabase in the event that we carried out research potentially relevant to you. In fact, you asked that we contact you in the event that we initiated such a research project.
\par }\pard \ql \fi-1515\li810\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin810\itap0 {\fs22 
\par }\pard\plain \s15\ql \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 \fs22\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {Recently, the federal government passed legislation that affects our ability to co
ntact people who have requested to be included in health-related databases. That legislation, the Health Insurance Portability and Accountability Act (HIPAA), requires that we have written permission if we are to retain information such as your name, addr
ess, telephone number and health condition. Without your written permission, we will not be able to contact you about clinical research after April 14, 2003.
\par }\pard\plain \ql \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs22 
\par We have included a statement in this letter for you to review. If you are interested in remaining 
a part of our database and want to be contacted in the event that we begin a relevant clinical research project, we ask that you sign and return the statement in the self-addressed, stamped envelope that also is enclosed. This form allows us only to conta
ct you in the case of such a project - it does not allow us to release any identifying information to another party.
\par }\pard \qj \li0\ri0\sl-278\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par Please contact us at (314) xxx-xxxx if you have questions. Thanks again for your interest and support.
\par }\pard \qj \li0\ri0\sl-298\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {
\par 
\par Sincerely,
\par }\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 {\f1 
\par \sect }\sectd \linex0\sectdefaultcl \pard\plain \qc \li0\ri0\sl-250\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs22 SAINT LOUIS UNIVERSITY
\par }\pard \qj \li0\ri0\sl-269\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par 
\par }\pard \qc \li0\ri0\sl-269\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 Authorization to Maintain Personal Information
\par 
\par }\pard \qc \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 Clinical Trials Unit 
\par Department of XXX
\par }\pard \qc \fi-57\li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 麻豆视频下载 
\par }\pard \qc \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 [address]. 
\par }\pard \qc \fi-57\li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 St. Louis, MO 63104 
\par }{[phone number]
\par 
\par }\pard \ql \li0\ri0\sl-278\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
I would like for the Clinical Trials Unit in the Department of XXX at 麻豆视频下载 to retain my personal information in their database. This information will allow researchers or their staff to contact me if/when they are conducting research stu
dies that may be relevant to my (my ward's) health.
\par }\pard \ql \li0\ri0\sl-274\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 
\par The Clinical Trials Unit has my permission to retain the following information: name, address, telephone number, month/year of birth, and health condition (that is relevant to research that the Clinical T
rials Unit may conduct). The Clinical Trials Unit may not release this information to any party not directly involved in their clinical research }{enterprise.
\par 
\par }{\fs22 I understand that I may revoke this authorization at any time by giving verbal or written notice of my revocation at any time to the Clinical Trials Unit research staff at the phone number or address listed above.
\par }\pard \qj \li0\ri0\sl-221\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {
\par 
\par _________________________________\tab \tab _______________________________
\par Signature\tab \tab \tab \tab \tab \tab Date
\par 
\par 
\par 
\par __________________________________
\par }\pard \qj \li0\ri0\sl-298\slmult0\nowidctlpar\faauto\rin0\lin0\itap0 {\fs22 Name (print)
\par }\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 {\f1 
\par }}