Ordering care providers will complete the notification/prior authorization process online or over the phone. The Human Subjects Office has a developed a Frequently Asked Questions page to provide some guidance for how to use HawkIRB. Referral to Periodontics - Electronic or Printable 9. Registering new patients or learning about previous medical history are some of the processes made easier with our collection of online healthcare form templates. 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. 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. | Patient’s Legal Name: Birth Date: … 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. Department of Radiology 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. CONSENT FORM. Preferred Non-Solid Dosage Forms - Clinical Pharmacy Program Guidelines - … TennCare Public Notices; Katie Beckett Program; Redetermination; Need Language help? The Human Subjects Office in collaboration with Information Technology Services has developed a web-based IRB application and review system, called HawkIRB. #_____ 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. Hepatitis B. 3970 John Pappajohn Pavilion Groups or individuals who need HawkIRB training should contact the HSO at irb@uiowa.edu or (319) 335-6564. Hosp. Send copy of completed form to Health Information Management (HSSB, Suite 100) to be scanned into patient’s medical record. • All of my questions have been answered to my satisfaction. To request a pre-printed form be sent to you via e-mail or by mail, please e-mail HIM-ConsentForm@uiowa.edu. 200 Hawkins Drive Referral to Pediatric Dentistry - Electronic or Printable 8. 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 … Hardin Library, Office 105 Iowa City, IA 52242-1089, Copyright © 2021 The University of Iowa. PDF. Labs must register their tests to participate as part of the Genetic and Molecular Lab Testing Notification/Prior Authorization process. #:_____ University of Iowa Hospitals and Clinics (UIHC) Please use blue or black ink, neatly PRINT (except signature) and provide complete information in each section. #___________________. HawkIRB is a fully-integrated, web-based system for human subject researchers and the IRB. Referral to Oral & Maxillofacial Surgery 5. The forms are organized alphabetically by department with instructions for their use just a mouse click away. Referral to Endodontics - Electronic or Printable 2. University of Iowa ADMIN - CONSENT TO OBTAIN INFORMATION. The Human Subjects Office (HSO) was established by the Vice President for Research to provide administrative support for the University of Iowa Institutional Review Boards.An Institutional Review Board is a group of individuals charged with reviewing proposed research involving human subjects to ensure the protection of those subjects and compliance with federal human subjects regulations. 1. 1,063 Templates. Form 1991 . # University of Iowa Hospitals & Clinics (UIHC) Health Information Management Department, Release of Information Office, 200 Hawkins Dr., Iowa City, IA 52242. Student Involvement Immunization Form. Referral to Operative Dentistry - Electronic or Printable 4. Click for human subjects research training info: Human Subjects Office / IRB A consent form is a signed document that outlines the informed consent of an individual for a medical study, clinical trial, or activity. Review the University of Iowa Hospitals & Clinics patient rights and advocacy statement. • I know that the information in this form includes the known effects and risks. Form 1991 CONSENT TO OBTAIN INFORMATION Hosp. 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. Consent Form for Publication in a PLOS Journal I, the undersigned, give my consent for my or my minor child’s (insert name below, where indicated) photograph, other image or likeness, case history or family history to be published in a Public Library of Science (PLOS) Journal. AUTHORIZATION FOR BROKER TO ACT AS BENEFITS ADMINISTRATOR. 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. 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. Hosp. var bugzillaReferrer = window.location.href; Iowa City, IA 52242-1098, Voice: 319-335-6564 Vaccinia (Small Pox) OHC Smallpox Medical History and Consent Form. Under the Student Life Management heading is Academic Record Consent Form. 600 Newton Rd TDap. document.write('Report an Issue With This Page'); 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). • I have had enough opportunity to discuss treatment options with my health care provider. I also know that there may be unknown long-term effects or risks. 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. Skilled Nursing Facilities: UnitedHealthcare Clinical and Therapy Request Form. Sterilization Consent Form (English) Sterilization Consent Form (Español) Sterilization Consent Form FAQ; Stay Informed. Additionally, I agree that this Consent Form does not authorize anyone to receive individually identifiable health information about any Oxford member. The application can be found after logging into MyUI by clicking the Student Information tab. The school’s ability to discipline your child under the school’s disciplinary code and procedures. General Agent pursuant to this Consent Form. Tdap Vaccine Information & Waiver. Healthcare Forms. 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