HIPAA Research Authorization Form (UCOP version remains dated 2014)



Institutional Review Board

Human Research Protections (HRP)


Updated: HIPAA Research Authorization Form (UCOP version remains dated 2014)

Version January 14, 2020


Image result for HIPAAA new version of the HIPAA Research Authorization Form is now posted on the Applications and Forms webpage under the subsection, ‘Human Research Protections’ and then, ‘HIPAA Documents.’

Summary of Significant Changes:

·One form now covers UCI providers and non-UCI providers (note: off-site providers may still require that subjects complete their own versions of the HIPAA Research Authorization Form). 

·Prefilled form fields (e.g., name of sponsor) to help facilitate completing the form.

These changes were made to help improve compliance in executing the HIPAA Research Authorization, and have been reviewed by our partners at School of Medicine (SOM) – Compliance and Privacy Office as well as by the UC Office of the President.

New studies submitting to the IRB should utilize this updated template in cases where HIPAA Research Authorization is required. 

For existing studies, researchers may switch out their existing HIPAA Research Authorization Form (available on the IRB Document Depot) – with the new version, at their next IRB transaction. 

For additional information on HIPAA, visit our HRP HIPAA webpage, contact HRP Staff for questions, or reach out to the SOM Compliance and Privacy Office at: .

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