HIPAA Authorization to Use and Disclose Protected Health Information for Research

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Form last updated: June 10, 2026

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What is this Authorization?
‍This form, which we call an “Authorization,” is designed to obtain your permission for the use and disclosure (sharing) of your identifiable health information for certain purposes as described below. Please read this Authorization carefully. By agreeing to this Authorization, you confirm that you are at least eighteen (18) years of age. If you are accepting this document for another person (“Family Member”) as such Family Member’s guardian, conservator, or custodian, you certify that you have the legal authority to serve as the above named person’s legal representative, and you agree to the terms, conditions, and notices contained or referenced herein on behalf of such Family Member.

‍Who Is Allowed to Use and Disclose the Identifiable Health Information?
‍By agreeing to this Authorization, you allow Center for Neurohealth, Inc., doing business as Salma Health, Ocean Psychiatry, Inc., Salma Health LLC and their affiliated practices (collectively, “Salma Health”, “we”, or “us”) to use and share your identifiable health information for certain purposes as described below.

‍What Identifiable Health Information May Be Used or Disclosed?
‍The identifiable health information that we may use or share includes your name, date of birth, address, email address, phone number, medical history, lab tests, imaging results, symptoms, medication history, treatment history and other information that might be found in a medical record. In addition, the identifiable health information used and shared under this Authorization may include certain highly sensitive information about mental or behavioral health or psychiatric care.

‍Why Am I Being Asked to Agree to this Authorization?
We are asking you to agree to this Authorization to allow us to use and share your identifiable health information to join our research registry (the “Registry”) determine if you are eligible for various research studies that we may conduct or support, and to contact you about potential research studies.

‍Who Will Receive My Identifiable Health Information?
Your identifiable health information may be used by or shared with Salma Health and its employees, contractors and other members of its “workforce” as defined under HIPAA for the purposes described in this Authorization.

‍Do I Have to Agree to This Authorization?
This Authorization is voluntary and you can decide not to agree to it. If you decide to agree to it and later change your mind, you can revoke (take back) your permission at any time. We will not withhold or refuse to treat you if you refuse to agree to this Authorization or later decide to withdraw it.

‍How Would I Withdraw My Authorization If I Change My Mind? What Happens If I Withdraw?
You can take back your permission for us to use and share your identifiable health information at any time by sending an email to research@salmahealth.com.  Once we receive your withdrawal, we will stop collecting more identifiable health information about you for the purposes described above. However, if you take back your permission, it will not affect actions that we already took based on this Authorization before we received your written notice of withdrawal. Also, we may still use or share the information as necessary to maintain the integrity or reliability of our research recruitment activities. 

Because research recruitment is an ongoing process, we cannot give you an exact date when we will either destroy or stop using or sharing your identifiable information. Your permission to use and share your identifiable information expires upon the earlier to occur of (a) your withdrawal of your consent and (b) the termination of the Registry.

A copy of this authorization will be sent to your email address on file with us. By agreeing to this authorization, you confirm that we may send communications to you at this email address. 

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I HAVE READ AND UNDERSTAND THIS AUTHORIZATION. BY CHECKING THE BOX ASSOCIATED WITH AND AGREEING TO THIS AUTHORIZATION, I AUTHORIZE THE USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION AS DESCRIBED ABOVE.