Medical Validation (Attachment 3)

Attachment 3

Revised authorization initial request letter to participant

March 29,20 11

((fname))((lname))
((address1))
craddress2))
((city)),((state)) (cpostalcode))
Dear ((title))((lname)):
Thank you for participating in our health study of radiologic technologists. We are now in the
process of collecting additional information from physicians and hospitals on selected cancers or
benign conditions reported by study participants in order to ascertain the relationship between
health and occupational radiation exposure.
We are contacting you to request your permission to obtain copies of pathology reports or other
medical procedures related to your diagnosis. Please review and sign both copies of the release
form and return one copy in the enclosed postage-paid envelope at your earliest convenience.
(Keep the second copy for your own records.)
J

The HIPAA Authorization to Use and Disclose Individual Health Information for
Research Purposes - This form is required as part of the federal privacy regulations,
Health Insurance Portability and Accountability Act of 1996, which went into effect on
April 14,2003.

Please be assured that all information provided will be kept private under the Privacy Act, and will not
be disclosed to anyone but the researchers conducting this study or as provided by law. Published
results will be reported in statistical summaries only, and will never include a participant's name. This
study is authorized under Section 41 1 of the Public Health Service Act [42 USC 285al. YOLI~
participation in this study is completely voluntary, and failure to answer any particular questions or the
information collection as a whole will not affect your future contacts with the A.R.R.T., any medical
facility, or govelllment agency.
Thank you for your cooperation in this important endeavor. If you have any questions, please call
the study office at 1-800-447-6466or 6 12-625-1151.
Sincerely yours,

Bruce H. Alexander, Ph.D.
Professor and Principal Investigator

MVC-HIPAA-BBT 0212011

In collaboration with the American Registry of Radiologic Technologists and the National Institutes of Health

((cohort-id))

Attachment 3

Revised authorization 2nd request letter to participant

March 29,201 1
((fname))ctlnarne))
((address1)) ctaddress2~
((city)),((state)) ccpostalcode))
Dear ((title))((lnarne)):
Several weeks ago we mailed a request for some additional information regarding the medical
conditions you reported in your survey. In the event that you did not receive that communication,
or if you have misplaced the original copy, we have enclosed additional forms for your
convenience.
As explained in the previous letter, we are now in the process of collecting additional information
fiom physicians and hospitals on selected cancers or benign conditions reported by study
participants in order to ascertain the relationship between health and occupational radiation
exposure.
We are contacting you to request your permission to obtain copies of pathology reports or other
medical procedures related to your diagnosis. Please review and sign both copies of the release
form and return one copy in the enclosed postage-paid envelope at your earliest convenience.
(Keep the second copy for your own records.)
J

The HIPAA Authorization to Use and Disclose Individual Health Information for
Research Purposes - This form is required as part of the federal privacy regulations,
Health Insurance Portability and Accountability Act of 1996, which went into effect on
April 14,2003.

Please be assured that all information provided will be kept private under the Privacy Act, and will not
be disclosed to anyone but the researchers conducting this study or as provided by law. Published
results will be reported in statistical summaries only, and will never include a participant's name. This
study is authorized under Section 41 1 of the Public Health Service Act [42 USC 285al. Your
participation in this study is completely voluntary, and failure to answer any particular questions or the
information collection as a whole will not affect your future contacts with the A.R.R.T., any medical
facility, or government agency.
Thank you for your cooperation in this important endeavor. If you have any questions, please call
the study office at 1-800-447-6466or 6 12-625-1151.
Sincerely yours,

Bruce H. Alexander, Ph.D.
Professor and Principal Investigator

MVC-HIPAA-BBT 021201 1

In collaboration with the American Registry of Radiologic Technologists and the National Institutes of Health

((cohort-id))

Attachment 3

Revised initial request letter to physician

April l , 2 0 11
((DRFACILI))
(t ADR 1))
(tADR2))
((city)),((state)) ((zip))
Request for Medical Records Enclosed

Patient:
Birthdate:

((fname))ctmname)) ctlname))
((DOB))
(t SSN),
Please search for any diagnosis of cancer or benign
(+I-one year).
brain tumor from <>
Dear ((salute)):
The Division of Environmental Health Sciences at the University of Minnesota's School of Public Health
and the National Cancer Institute are currently investigating the effects of low dosage radiation on
radiologic tecl~nologists.This study, entitled "U.S. Radiologic Technologists Study" is being conducted
with the cooperation of the American Registry of Radiologic Tecl~nologists(A.R.R.T.), is authorized
under section 41 1 of the Public Health Service Act (42 USC 285a).
The patient named above is participating in a study designed to assess the health of former and current
radiologic technologists. We are requesting specific diagnostic information from health care providers
for cancers or benign brain conditions reported by the study participant. We would be most appreciative
if you would send us copies of the pathology reports, or if unavailable, please send us clinical summaries
or other medical records referring to the diagnosis.
Please find enclosed a signed HIPAA authorization form for the release of medical records. All
infornlation you provide will be kept private under the Privacy Act and will not be disclosed to anyone
but the researchers conducting this study, or as provided by law. The findings of the survey will be
published in a peer-reviewed scientific journal. Published results will be reported in statistical summaries
only, and will never include a participant's name.
Thank you in advance for your cooperation. We greatly appreciate the time and effort involved in
complying with our request. Should you have any questions, please do not hesitate to call the study office
at 612-625-1 151 or 1-800-447-6466.
Sincerely yours,

Bruce H. Alexander, Ph.D.
Professor

In collaboration with the American Registry of Radiologic Technologists and the National Institutes of Health

Attachment 3

Revised 2nd request letter to physician

April 1, 20 11

Request for Medical Records Enclosed
ctfnarnen L ((lname))
((DOB))
(( SSN))
Please search for any diagnosis of cancer or benign
brain tumor from <>
(+I- one year).

Patient:
Birthdate:

I

Dear ((salute)):
Several weeks ago we mailed a request for some specific medical information to you regarding one of
your patients. In the event that you did not receive that communication, or if you have misplaced the
original copy, we have enclosed an additional form for your convenience. As explained in the previous
letter, the patient named above is participating in a study designed to assess the health status of former
and current radiologic technologists. This study, sponsored by the National Institutes of Health and in
cooperation with the American Registry of Radiologic Technologists (A.R.R.T.), is authorized under
section 41 1 of the Public Health Service Act (42 USC 285a).
In order to classifL this participant correctly, we are requesting specific diagnostic information fiom the
participant's health care providers. We would be most appreciative if you would send copies of patholow
reports, or if unavailable, please send us clinical summaries or copies of other medical records referring to
the diagnosis.
Please find enclosed a signed HIPAA a~lthorizationform for the release of medical records. As always,
any information you provide will be kept private under the Privacy Act and will not be disclosed to
anyone but the researchers conducting this study, or as provided by law. The findings of the survey will
be published in a peer-reviewed scientific journal. Published results will be reported in statistical
summaries only, and will never include a participant's name.
Thank you in advance for your cooperation. We greatly appreciate the time and effort involved in
complying with our request. If you have already returned the form, please disregard this letter. Should
you have any questions, please do not hesitate to call the study office at 612-625- 1151 or
1-800-447-6466.
Sincerely yours,

Bruce H. Alexander, Ph.D.
Professor

In collaboration with the American Registly of Radiologic Technologists and the National Institutes of Health