Release of Information Office (Telephone 319-356-1719; FAX 319-356-3079) Please neatly PRINT (except signature) and provide complete information in each section. Referral to Implant Screening Clinic - Electronic or Printable 3. Click for human subjects research training info: Human Subjects Office / IRB Controlled Substance Co-Signing Form; Film Repeat Rate by Technologist and Clinical Area ; Integrity of Lead Aprons and Thyroid … 3970 John Pappajohn Pavilion Starting Nov. 1, 2017, notification is required for certain genetic and molecular lab tests for certain UnitedHealthcare Commercial benefit plans. (Protects the school if the child is exposed to inappropriate online content). 1,063 Templates. ADMIN - CONSENT TO OBTAIN INFORMATION. #_____ UI Sports Medicine and University of Iowa Hospitals and Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Revised: 12-2018 Original: Scan into Epic Copy: Patient. LAST MODIFIED 09.29.2020. Referral to Prosthodontics - Electronic or Printable 10. #___________________. Review the University of Iowa Hospitals & Clinics patient rights and advocacy statement. University of Iowa Hospitals & Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Search by state, line of business, and product to locate a form or application. The Human Subjects Office in collaboration with Information Technology Services has developed a web-based IRB application and review system, called HawkIRB. Healthcare Forms. Vaccinia (Smallpox) Vaccine Request Form and Use Agreement. Parents/guardians of students are presented to execute their authority to either give or decline consent to a school overseeing their child. Whether you’re looking for a way to gather model releases, activity waivers, parental consent, or medical consent forms, you can start by selecting one of our 400+ Consent Form … Nondiscrimination Statement, Up-to-date information regarding COVID-19 for College of Medicine students and researchers, Assigning On-Call Responsibilities for General Radiology, On-Call Policy for Interventional Radiology Nursing Staff, Administration of Contrast via Indwelling CVC in the Adult or Pediatric Patient, Administration of Enteric and IV Contrast on Inpatient Unit, Adult Contrast Reaction Management in SFCH LL2, Contrast Policy for Adult Patients Receiving CT Abdomen/Pelvis: Bladder Cancer, Contrast Protocol for CTA Brain and Cerebral Perfusion and CT Brain, CTA Brain and Cerebral Perfusion, Education Sheet for Patients Receiving IV Contrast, Intraosseous Iodinated Contrast Injection Guidelines, IV Contrast Administration for Patients with Limited English Proficiency, Policy on Education for Patients Receiving IV Contrast, Protocol for Adult CT Abdomen/Pelvis Trauma with Delays (Cysto); CT Abdomen/Pelvis Trauma w/o Delays; CT Chest, Abdomen/Pelvis with delays; all of which can be done w/wo IV Contrast, Protocol for Adult CT Chest, Abdomen/Pelvis with Contrast Media; CT Chest, Abdomen/Pelvis without Contrast Media in Patients for Follow-up Melanoma and Sarcoma, Protocol for Adult CTA of Head with Contrast Media; CTA of Neck with Contrast Media; CTA of Head and Neck with Contrast Media, Protocol for Adult Patients Receiving CT for Abdomen/Pelvis with Contrast Media or Abdomen/Pelvis without Contrast Media in Acute Abdomen and/or Pelvis, Protocol for Adult Patients Receiving CT Abdomen with Contrast Media; CT Abdomen and Pelvis with Contrast Media; CT Chest, Abdomen and Pelvis with Contrast in Patients for Biphasic Liver Exams, Protocol for Adult Patients Receiving: Right, Left and Bilateral CT Angio Lower Extremity w/wo Contrast; CT Angio Abdomen/Pelvis with Bilateral Lower Leg Runoff w/wo; CT Angio Pelvis with Single Lower Extremity Runoff w/wo, Management of Unresolved Serious Complaints in Breast Imaging, Self and Direct Referral Patients for Mammography, Body Imaging Percutaneous Procedures Anticoagulation Guidelines, CT IV Size Protocol for Pediatric Patients, CT of Patients with Implantable and External Electronic Medical Devices, Policy for Routine CT Abdomen without Contrast Media for Post Chemo Embolization, Hernia, and Follow-up Drainage Tube Placement by Interventional Radiology, Portable Head Computed Tomography (CT) without Contrast Media, Protocol for Routine CT Abdomen/Pelvis without Contrast Media for Renal Stones, Hernia, and Follow-Up Drainage Tube Placement by Interventional Radiology, Image Management After Hours Staff for Archive Corrections, Image Management Archive Corrections After Hours, Release of CD Exams to Patient and/or Another Party, ardiac Stress Testing of Adult Patients Using MR Imaging, Emergency Situations in the MR Environment, MR Imaging of Adult Patients with FDA-Approved Cardiac Implantable Electronic Devices (CIED), MR Imaging Protocol for Patients with Implanted Neurostimulators, MRI of Pediatric and Adult Congenital Heart Disease (ACHD) Patients with FDA-Approved Cardiac Implantable Electronic Devices (CIED), Procedure for Patients that are Breast Feeding After the administration of Gadolinium Intravenously, MRI Scanning of Patients with Intravascular Stents, Coils and Heart Valves, Fine Needle Spinal Procedures and Anticoagulation, Call Tree for Full Scale Hospital Disaster, Code Blue Responsibilities for Radiology Staff, Radiant Quicksheet - EPIC Downtime Process, Career Development for Imaging Technologists, Charge Technologist in the Department of Radiology, CT Weekend Option and Weekend Scheduling to Cover Vacation for Weekend Option, Diagnostic Radiology Protocol for Assuring Registration/Certification/Permit Compliance, Dress Code Policy for Clinical Staff in Diagnostic Radiology, Guidelines for Monitoring and Correcting Technical Errors, Guidelines for the Use of Personal Electronic Devices - Diagnostic Radiology, Licensure and Certification for Technologists and Sonographers, MR and CT Call Coverage During Vacancy/Illness, MRI Weekend Option and Weekend Scheduling to Cover Vacation for Weekend Option, Reclassification Application for Imaging Technologists, Reporting Concerns Regarding Clinical Quality, Protocol for Oral Diazepam and/or Lorazepam for Outpatient Adult MRI, Nuclear Medicine and Ultrasound Patients Requiring Oral Sedation, Informed Consent, Time Out and Site Marketing, Information Sheet for Undergoing an MRI During Pregnancy, Policy for Pregnant or Possibly Pregnant Patients, G-2d2 Consent Form for Imaging of the Abdomen or Pelvis in Pregnancy where the Dose is 1-5 rem, G-2d2 Consent Form for Imaging of the Abdomen or Pelvis in Pregnancy where the Dose is Greater than 50mSv (5 rem), Procedure for Imaging Patients that are Pregnant Utilizing an MRI Scanner, Film Repeat Rate by Technologist and Clinical Area, Integrity of Lead Aprons and Thyroid Shields, Integrity of Radiation Protection Equipment Form, Interoperative Shielding During Fluoroscopy Guided Exams in the Pediatric Patient, Mandatory Admission due to Postoperative Apnea Risk Following Sedation and Anesthesia for Infants, Management of Adverse Patient Events or Outcomes in the Radiology Department, Monitoring for Apnea after General Anesthesia, Deep Sedation or Spinal Anesthesia in Young Infants, OR Images for Sponge Count or Foreign Object, Radiation Protection Guide for Medical Use of Radioactive Materials & Radiation Producing Machines, Radiology Bariatric Chair Location Log Sheet, Suggested Procedure for Contacting Caregivers, Witnessing the Disposal of Controlled Substances, Critical Results Requiring Immediate Clinical Notification - Chest, Critical Results Requiring Physician Notification. # University of Iowa Hospitals & Clinics (UIHC) Health Information Management Department, Release of Information Office, 200 Hawkins Dr., Iowa City, IA 52242. 200 Hawkins Drive UIHC patients only CONSENT TO RELEASE OF INFORMATION Hosp. • All of my questions have been answered to my satisfaction. Hosp. Consent Forms Adult Hereditary Cancer CMA NY State GeneAware Huntington Disease Informed Consent for Genetic Testing ... Beginning January 1, 2016, UHC requires prior authorization form for BRCA testing to be filled out for genetic testing. All Rights Reserved Fax: 319-335-7310irb@uiowa.edu, HawkIRB Development and Implementation Process, forms and/or instructions that are not available on the HawkIRB, UI Investigator's Guide\IRB Standard Operating Procedures, Central & External IRBs (Single IRB of Record), on-line submission of application forms and Consent Documents, an electronic workflow process through which you will communicate with the IRB regarding review and approval of your applications, a "My Projects" home page through which you will be able to view detailed IRB workflow information about all of your projects, IRB approval memos and stamped Consent Documents returned to you electronically -- no more waiting for campus mail, reminder notices for continuing review sent by e-mail to PIs and contact persons, applications for new projects, modifications, and continuing reviews, forms for reporting unanticipated problems and adverse events (REFs), consent templates (standard informed consent, VAMC informed consent, UIHC Record of Consent, Assent, Spanish "short form" consent, consent as a letter). Use our HIPAA-compliant form to authorize the release of medical information - Consent to Release of Information. Department of Radiology Phase 1 Standardize documenting when a patient refuses blood products Future phases may include development of: Make documentation more visible in Epic with new […] Other procedure-specific consent forms … | I have seen and read the material to be published. 2. Iowa KidSight is a joint project of the Lions Clubs of Iowa and the Department of Ophthalmology & Visual Sciences at the University of Iowa Stead Family Children’s Hospital, dedicated to enhancing the early detection and treatment of vision impairments in young children (target population 6 months of age through kindergarten) in Iowa communities through screening and public education. AUTHORIZATION FOR BROKER TO ACT AS BENEFITS ADMINISTRATOR. UHC – MEDICATION SOURCING EXPANSION PRESCRIBER ORDER FORM: Submit completed form and clinical documentation. UHC Members should call the number on the back of their ID card, and non-UHC members can call 888-638-6613 TTY 711. Referral to Endodontics - Electronic or Printable 2. #:_____ University of Iowa Hospitals and Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Broker Authorization: The undersigned hereby requests Oxford Health Plans to accept the Broker or General Agent named below as an authorized Benefits Administrator for purposes of processing any enrollment transactions for my company’s Oxford Health Plan policy (including, but not limited to, Member … The forms are organized alphabetically by department with instructions for their use just a mouse click away. #_____ University of Iowa Hospitals and Clinics (UIHC) Health Information Management Department; Release of Information Office 200 Hawkins Dr., Iowa City, IA 52242 (Telephone 319-356-1719; FAX 319-356-3079) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. I also know that there may be unknown long-term effects or risks. Patient consent forms: Panel tests: Patient informed consent Panel tests (Spanish): Patient informed consent Exome tests: Patient informed consent Authorization to use and disclose health information Please note that there is no paper requisition form for exome testing. Roy Carver College of Medicine Sterilization Consent Form (English) Sterilization Consent Form (Español) Sterilization Consent Form FAQ; Stay Informed. HIM and the Quality Improvement Program have developed a new Consent for Refusal of Blood Products form and document type ‘Consent for Refusal of Blood Products.’ This is a multi-phase project. Patient’s Legal Name: Birth Date: … Any claim (hospital, operating physician, anesthesiologist, clinic, etc) involved in a sterilization procedure must have a properly completed Consent Form attached when it is submitted for payment. Standalone authorization. Form 1989 CONSENT TO RELEASE OF INFORMATION Hosp. Web Privacy Policy #_____ University of Iowa Hospitals and Clinics (UIHC) Health Information Management Department; 200 Hawkins Drive, Iowa City, IA 52242 . Patient’s Legal Name _____ Birth Date _____ I, the undersigned, hereby authorize: Requested format: ____ FAX ____ CD ____ Copies . CONSENT TO OBTAIN INFORMATION . consent templates (standard informed consent, VAMC informed consent, UIHC Record of Informed Consent, Assent, Spanish “short form” consent, consent as a letter) project closure form; Consent forms, scripts, advertisements, and other materials can be uploaded to HawkIRB during your application. The HawkIRB system includes: Consent forms, scripts, advertisements and other materials can be uploaded to HawkIRB during your application. Field trip permission – By a parent giving consent, their chil… You may use this form to revoke your consent, or you may submit some other written evidence of your intent to revoke consent, if you prefer. CONSENT FORM. Form 1989 CONSENT TO RELEASE OF INFORMATION Hosp. Iowa City, IA 52242-1098, Voice: 319-335-6564 Click  here for forms and/or instructions that are not available on the HawkIRB system, but that you might be asked to submit with your application. 3. If you have any problems or questions regarding HawkIRB, check out our FAQ page or contact the HSO staff. General Agent pursuant to this Consent Form. The application can be found after logging into MyUI by clicking the Student Information tab. Skilled Nursing Facilities: UnitedHealthcare Clinical and Therapy Request Form. If you would like to submit a question for consideration as an addition to the FAQ, please send an e-mail to hawkirb@uiowa.edu. Vaccinia (Small Pox) OHC Smallpox Medical History and Consent Form. Form 1991 . Individuals can also report potential inaccuracies via phone. TennCare Public Notices; Katie Beckett Program; Redetermination; Need Language help? PDF. A consent form is a signed document that outlines the informed consent of an individual for a medical study, clinical trial, or activity. #_____ University of Iowa Hospitals and Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. Standalone authorization form (pdf) Standalone personal representative form (pdf) These optional forms are used by the member to provide UnitedHealthcare with authorization to … Reporting issues via this mail box will result in an outreach to the provider’s office to verify all directory demographic data, which can take approximately 30 days. Referral to Oral & Maxillofacial Surgery 5. UIHC Policy for External Images ... G-2d2 Consent Form for Imaging of the Abdomen or Pelvis in Pregnancy where the Dose is Greater than 50mSv (5 rem) Procedure for Imaging Patients that are Pregnant Utilizing an MRI Scanner; Radiology Quality and Compliance. Referral to Oral Pathology, Radiology & Medicine 7. I acknowledge that I must notify Oxford in writing to void this agreement in the event of a change in my company‘s Broker of Record. Important Information About Vaccinia (Smallpox) Vaccine. University of Iowa 1. All applications for UI IRB review must be submitted through HawkIRB. Preferred Non-Solid Dosage Forms - Clinical Pharmacy Program Guidelines - … You were given this consent form because your care provider would like to involve in your care a provider that is not in our network. A summary of the HawkIRB Development and Implementation Process was presented to the Associate Deans for Research on 1/28/04. Form 1989 CONSENT TO RELEASE OF INFORMATION Hosp. Iowa City, IA 52242-1089, Copyright © 2021 The University of Iowa. Our goal was to develop a nearly-paperless system that provides much more information to the investigator about the IRB review and approval process as it occurs. forms for reporting unanticipated problems and adverse events (REFs) consent templates (standard informed consent, VAMC informed consent, UIHC Record of Consent, Assent, Spanish "short form" consent, consent as a letter) project closure forms; Consent forms, scripts, advertisements and other materials can be uploaded to HawkIRB during your application. Registering new patients or learning about previous medical history are some of the processes made easier with our collection of online healthcare form templates. Web-based, primarily electronic systems appear to be the future direction for IRBs and investigators, and similar systems are currently being developed at other major academic institutions. For your convenience, group and member enrollment forms and applications can be downloaded from this website. To request a pre-printed form be sent to you via e-mail or by mail, please e-mail HIM-ConsentForm@uiowa.edu. It can only be ordered online. Hardin Library, Office 105 (Non-patient forms are retained by the department acquiring consent). Welcome to the University of Iowa Electronic Forms home page. Labs must register their tests to participate as part of the Genetic and Molecular Lab Testing Notification/Prior Authorization process. The Human Subjects Office has a developed a Frequently Asked Questions page to provide some guidance for how to use HawkIRB. • I have had enough opportunity to discuss treatment options with my health care provider. University of Iowa Student Consent For Release of Academic Records Students may grant permission for the University to disclose or discuss student record(s). Hosp. The Consent Form is a replica of the form contained in the Federal Regulations and must be utilized by providers when submitting claims for sterilization procedures. Suite 100 ) to be scanned into patient ’ s medical record the IRB child to access the ’! And non-UHC Members can call 888-638-6613 TTY 711 content ) the child is exposed to online... Forms.Uihc.Uiowa.Edu/Medicalrecordsforms.Htm, as of Dec. 1, 2016 only Consent to a school seeks obtain! … UIHC patients only Consent to RELEASE of medical Information - Consent to a school seeks to obtain Consent are. Information about any Oxford member the school if the child to access school... Medication SOURCING EXPANSION PRESCRIBER ORDER form: Submit completed form and Clinical documentation be printed from the Point forms.uihc.uiowa.edu/medicalrecordsforms.htm. The number on the back of their ID card, and product to locate a form or.... Required for certain UnitedHealthcare Commercial benefit plans genetic and molecular lab Testing notification/prior authorization.... Form or application authority to either give or decline Consent to a school seeks to obtain Consent which are 1! 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Clinical Pharmacy Program Guidelines - … DOT medical Examination Report form HawkIRB is a fully-integrated web-based... Hawkirb system includes: Consent forms, scripts, advertisements and other materials be...

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