Trial Interest

PRIVACY INFORMATION

 

Neuropsychiatric Research Center of Southwest Florida considers your privacy a foremost concern and we will use every reasonable means to protect your personal health information.

 

Neuropsychiatric Research Center of Southwest Florida will not share, sell, or otherwise distribute your personal information or related data to any outside person or entity in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. Our HIPAA Notice of Privacy Practices can be downloaded on our medical history and information page. On this page you will also find a HIPAA Privacy Rule document from the U.S. Department of Health & Human Services that discusses information that may be used or disclosed by covered entities for research purposes.

 

"Neuropsychiatric Research Center of Southwest Florida considers your privacy a foremost concern."

 

TRIAL INTEREST

 

If you are interested in participating in one of our studies or would simply like more information about our studies, please complete and submit the Clinical Trial Interest Form below.

 

The purpose of this form is to provide us with information on what studies interest you. Moreover, it will help us determine the studies for which you are eligible to participate. Information provided in greater detail will help expedite the screening process for both you and us; however, you do not have to answer any question that you do not want to answer.

 

 

If you submit this form, someone from our office will contact you about your submission data within 5 business days.

 

MEDICAL HISTORY

 

Please download the medical history form using the link below. If you or someone you care for plans to participate in a clinical trial at our site, please complete this form with the patient's health information and bring it to the first visit. If you need more space to clarify the patient's medical history, please feel free to amend the document as needed. If you would rather fax the form to us, that would be fine as well. Thank you.

 

Medical History Form

 

 

PLEASE REVIEW THESE HIPAA RELATED DOCUMENTS

The links below allow you to download important documents pertaining to HIPAA and Clinical Trials. This information will help clarify the health information procedures that are mandated by law for medical research facilities.

 

HIPAA Notice of Privacy Practices

 

HIPAA description on research

 

Pre-Screening Informed Consent

 

Pre-Screening Release of Information

 

 

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Neuropsychiatric Research Center of Southwest Florida

14271 Metropolis Avenue, Suite A • Fort Myers, FL  33912