Coordinated Clinical Research (CCR) is a research organization dedicated to conducting clinical trials. Clinical trials (also called medical research and research studies) are used to determine whether new drugs or treatments are both safe and effective. The law requires us to get your authorization (permission) before we can use your information or share it with other for research purposes. The information you provide will be entered into a patient database to be used solely for the purpose of conducting clinical trials. Only the doctors, coordinators, and employees of Coordinated Clinical Research will have access to this information. You can choose to sign or not to sign this authorization; however, if you choose not to sign this authorization, you will not be able to enter your information into our database.

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this information is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.

1. The health information that may be used and disclosed includes:
   • Name, address, phone number, and date of birth.
   • Medical/surgical/medication history relevant to participation in research
2. The Person/Organization that may provide this information:
   

   Coordinated Clinical Research
   9850 Genesee Ave, Suite 320
   La Jolla, CA 92037

3. The Person/Organization that may receive this information:
   

   Coordinated Clinical Research
   9850 Genesee Avenue, Suite 320
   La Jolla CA, 92037

4. Purpose of the use or disclosure: Medical Research Purposes Only
5. This authorization will expire on 1/1/2055.

I understand that my healthcare and the payment for my healthcare will not be affected by my signing this form.

I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form after I sign it.

I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it won’t have any affect on any actions they took before they received the revocation.