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Aloha Dermatology Clinic

Susan Tobey Denman, MD
18345 SW Alexander Street Suite B
Aloha, OR 97003
(503) 649-9477
(503) 649-1272 fax


Office Hours: Mon-Thurs 9:00-5:00

Diseases of the skin, hair, and nails.



July 1, 2006

Notice of Your Right to Decline Participation
in Future Anonymous or Coded Genetic Research


The State of Oregon has laws to protect the genetic privacy of individuals. These laws give you the right to decline to have your health information or biological samples used for research. A biological sample may include a blood sample, urine sample, or other materials collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect the care you receive from your health care provider or your health insurance coverage.

Research is important because it gives us valuable information on how to improve health, such as ways to prevent or improve treatment for heart disease, diabetes, and cancer. Under Oregon law, a special team reviews all genetic research before it begins. This team makes sure that the benefits of the research are greater than any risks to participants.

In anonymous research, personal information that could be used to identify you, like your name or medical record number, cannot be linked to your health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample so it would be very difficult for someone to link your personal information to your health information or biological sample. Your identity is protected in both types of research.

If you want to allow your health information and biological sample to be available for anonymous or coded genetic research, you don't have to do anything. If you make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you.

If you want to decline to have your health information and biological sample available for anonymous or coded genetic research, you must tell your health care provider by:


  • Print this page. Fill out and give it to your health care provider, or
  • Print this page. Fill out and mail it to the address provided above


Your decision is effective on the date your health care provider receives this form.

If you have any questions or concerns about this notice, please contact
Dr. Susan Denman at 503-649-9477.

No matter what you decide now, you can always change your mind later. If you change your mind, tell your health care provider your decision in writing by sending a letter to the address noted above. If you change your mind, the new decision will apply only to health information or biological samples collected after your health care provider receives written notice of your new decision.

I decline to have my health information and biological samples available for anonymous or coded genetic research.

____________________________________
Printed Name


____________________________________
Signature


____________________
Birthdate (mm/dd/yyyy)


___________________________________
Street Address, Apt #


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City, State, Zip Code







Dr. Susan Denman



Aloha Dermatology Clinic. All Rights Reserved, 2011.