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Request an Honest Broker Account

Name *

Job Title *

Department/School *

Contact Email *

Provide an email address where you would like a copy of your application sent to and would most likely be a work email.

TIES Study Name *

Specify the name of an existing TIES study that you need to be added to.

Report Types Accessed *

Pathology

Radiology

Both

Existing TIES Account? *

Yes

TIES Username *

Work Address *

Apt, suite, etc.

Country

City

State

Zip code

Work Phone *

Work Fax

Next - Supporting Documents

Supporting Documents

UPMC Honest Broker Application *

Honest Broker Approval Letter *

Agreements *

have access to identified pathology reports through coPath or MARS as part of my daily workflow.

will use TIES for the purposes of my current research only.

will follow all applicable criteria outlined in the UPMC Policy and Procedure Manual. Specifically - Policy: HS-EC1807; Index Title: Ethics and Compliance; Subject: Honest Broker Certification Process Related to the De-identification of Health Information for Research and Other Duties/Requirements of an Honest Broker. Source document located at: http://www.irb.pitt.edu/hipaa/HSEC1807.pdf

I agree at the time of this TIES Account Request, and at each and every TIES login, that I:

Next - Submit Application

Captcha *

Request an Honest Broker Account

Next - Supporting Documents

Next - Supporting Documents

Next - Submit Application

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