UNIVERSITY OF CALIFORNIA, IRVINE

Department Name	_____________________________
Program Name		______________________________
Building location		______________________________
Irvine, CA 92868- Zot #	_____ 
Phone number	________________

Principal Investigator Name:____________________

Acknowledgement of Patient Compensation

This document is to inform you that patient compensation exceeding $599.99 annually may result in:

a)	Your name, address, and social security number being released to the University of California, Irvine Accounting office.
b)	The receipt of a 1099 taxable income form from the University of California, Irvine.
c)	Alteration of your current entitlements benefits package.

I have read and discussed the above information with the study personnel and have been given the opportunity to ask questions and receive answers. I acknowledge that I waive my confidentiality rights if my annual patient compensation exceeds $599.99.

	
Signature of Subject or Authorized Legal Representative	Date

Print Name of Subject or Authorized Legal Representative

	
Signature of Witness	Date

Subject SS#:________________________________

Address:	

City:  	

Zip Code:	

Revised 7/21/99