This is example of a HIPAA Waiver of Authorization form. If a study meets the general criteria needed to ask for such a waiver, a form like this one would typically be submitted as an addendum to the initial IRB application. Click here to download.
Pace WD, Staton EW, Holcomb S. Practice-based research network studies in the age of HIPAA. Annals of Family Medicine. 2005;3(Suppl 1):S38-S45. http://www.annfammed.org/cgi/data/3/suppl_1/s38/DC1/4
