Right to Refuse to Sign this Authorization. I do not have to sign this authorization. My decision not to sign this authorization will not affect any treatment, payment, or enrollment in health plans or eligibility for benefits. However, if I do not sign this authorization, I may be denied the ability to work at hospital and clinic sites which require immunization information.
Right to Refuse to Sign this Authorization. You do not have to sign this Authorization. However, because your health information is required for research participation, if you decide not to sign this Authorization form, it will only mean you cannot take part in this research. Not signing this form will not affect your non-research related treatment, payment or enrollment in any health plans, or your eligibility for other medical benefits. Signature of subject I have read (or someone has read to me) the above information. I have been given an opportunity to ask questions, and my questions have been answered to my satisfaction. I authorize the use and release of my protected health information for this research. I will be given a signed copy of this Authorization form. ____________________________________ Printed Name of Subject ____________________________________ _______________ Signature of Subject Date ____________________________________________ _______________ Signature of Person Obtaining Authorization Agreement Date Version Number: __________
