Medical Archives - MedArchives OnCall

Make a Request

MedArchives OnCall

Home > Make a Request > MedArchives OnCall

Learn more about MedArchives OnCall.

If you have any questions about filling out this form, please contact the Medical Archives at (410) 735-6800 or at archives@jhmi.edu. Thank you.

Title
First Name *
Last Name *
Affiliation *
Mailing Address *
City *
State *
Zip/Postal Code *
Country *
Phone Number *	(123-456-7890)
E-mail Address: *
Please read and acknowledge acceptance of our policies. Part 1: Rights to Privacy I understand that the materials to which I have requested access may contain protected health information ("PHI") as defined under Privacy Regulations issued under the Health Insurance Portability and Accountability Act ("HIPAA Privacy Rule")1. If I encounter PHI in my access to the materials, I agree to make no notes or other recordation of the PHI and agree not to re-disclose the PHI to any other party for any purpose without the express permission of the Alan Mason Chesney Medical Archives ("Archives"). I understand that the materials to which I have requested access may contain confidential information, which is otherwise protected under federal or state law or regulation or Johns Hopkins policies. I agree to make no notes or other recordation of confidential materials and agree not to re-disclose the confidential material to any other party for any purpose without the express permission of the Archives. I understand that if I request copies of materials in the Archives, any PHI or confidential information will be redacted unless I have specific authorization to copy the materials or other specific exceptions apply. Part 2: Rights to Intellectual Property The Johns Hopkins University and The Johns Hopkins Hospital hold intellectual property rights to some, but not all, materials in the Archives. Some material to which you have requested access may still be protected by copyright and by the intellectual property laws of the United States2 and the Berne Convention3. You are solely responsible for obtaining permission for use from the holder (the institution, the author, heirs, legatees, or literary executors) of the intellectual property. After release to you of the materials, The Johns Hopkins University and The Johns Hopkins Hospital assume no responsibility for any infraction of intellectual property laws or for any other improper or illegal use that may arise from your utilization of materials from the Archives. 1 Protected Health Information means "individually identifiable health information, held or maintained by a covered entity [such as the Alan Mason Chesney Medical Archives] or its business associates acting for the covered entity, that is transmitted or maintained in any form or medium [...]. This includes identifiable demographic and other information relating to the past, present, or future physical or mental health or condition of an individual, or the provision or payment of health care to an individual that is created or received by a health care provider, health plan, employer, or health care clearinghouse". Reference: U.S. Department of Health and Human Services, National Institutes of Health; HIPAA Privacy Rule, Information for Researchers web site. Address: http://privacyruleandresearch.nih.gov/pr_07.asp 2 The copyright law of the United States (Title 17, USC) governs the making of photocopies or other reproductions of copyrighted material. Under certain conditions specified in the law, archives and libraries are authorized to furnish a photocopy or reproduction. One of these specified conditions is that the photocopy or reproduction is not to be "used for any purpose other than private study, scholarship or research." If a user makes a request for, or later uses, a photocopy or reproduction for purposes in excess of "fair use," that user may be liable for copyright infringement. This institution reserves the right to refuse a copying order if, in its judgment, fulfillment of the order would involve violation of copyright law. For more information please refer to U.S. Copyright Office: http://www.copyright.gov/title17/ 3 The Berne Convention is an international copyright treaty signed by 96 countries. The United States became a member of the Berne Convention on March 1, 1989. The regulations of The Berne Convention are more far-reaching than US Copyright Law. For more information please refer to U.S. Copyright Office: http://www.copyright.gov/fls/fl100.html/; http://www.copyright.gov/title17/circ92.pdf Part 3: Rules and Regulations for use of the Alan Mason Chesney Archives I understand that it is my obligation and responsibility to maintain the confidentiality of any PHI or confidential information that I may encounter. Improper re-disclosure of this information is a breach of confidentiality which could result in the loss of my access to the Archives. I also understand that improper re-disclosure of this information may constitute a violation of the Privacy Rule or other federal or state laws that could result in fines or other legal penalties. I understand that it is my obligation and responsibility to obtain authorization for the use of information and materials from the owners/licensees of intellectual property and persons of interest with respect to private information that is protected by law. I hereby waive any claim against The Johns Hopkins University and The Johns Hopkins Hospital for any liability should my use of materials from the Archives violate any state or federal laws concerning intellectual property or privacy. I also agree to indemnify and hold harmless the University and the Hospital for any liability resulting from any disclosure by me or redisclosure to others of the materials from the Archives. I understand that the Archives does not waive any proprietary rights to the materials being used, and that the Archives reserves the right to restrict access to any and all materials in its holdings. I agree to abide by the Rules and Regulations of the Archives.
* I have read and accept the policies.
Describe your request in detail. *


* Required