Electronic Permission to Share Contact Information with Researcher

CRG Laboratories is working with Science 37 to help identify patients who may be eligible to participate in a clinical trial to treat COVID-19.  You have been provided a very brief description of this study and you have expressed a willingness to allow us to share your contact information and your test results with the Science 37 research team.

Before we can do so, however, the HIPAA Privacy Rules require us to obtain your authorization. Please indicate below if you are still willing to allow CRG Laboratories to share contact information with Science 37. This will permit a member of Science 37 to contact you and provide you with more information about the COVID-19 treatment clinical trial.

I agree to permit CRG Laboratories to share the following information with Science 37. This is what will be transmitted to Science 37:

• My contact information (name, email address, telephone number) so that a member of the Science 37 clinical trial team can contact me
• My COVID-19 test results.

I am not obligated to participate in the study, and in fact, I am not obligated to complete this electronic authorization form. Whether I do, or do not, sign will not affect the services provided by CRG Laboratories.

Information about me will be kept as confidential as possible, and it will be shared only once, with Science 37.  No additional information about me will be shared (that is, this authorization will expire immediately after the information is shared).