WIC Participant

OMB Approval No. 0584-0580

Approval Expires: 05/31/2016

APPENDIX YY.1 HIPAA LETTER-English

«FirstName» «LastName»

«Address1» «Address2»

«City», «State» «Zip»

Dear «FirstName»,

We are happy to have you and «BabyFirstName» as part of the WIC Feeding My Baby study. Your participation is important in helping America learn about the choices WIC families make in feeding their children.

We would like your permission to get records about «BabyFirstName»’s birth from the hospital where you gave birth and to get the height and weight of <<BabyFirstNam>> from your baby’s doctor.

If you will agree to the release of this information, please check this box and sign one copy of the green Medical Release form (the other copy is for your records):

• I AGREE TO SIGN THE MEDICAL RELEASE FORM

If you do not agree, please check this box:

• I DO NOT AGREE TO SIGN THE MEDICAL RELEASE FORM

Please return your response and one signed copy of the Medical Release form (if you agree to sign it) in the postage paid envelope. Upon receipt of your response, we will add $5 onto your Payoneer card. You will receive $5 for your response, whether you agree to the release of your baby’s medical information or not.

If you have any questions, please contact your Study Liaison, «Study_Liaison_Name» at «Study_Liaison_Phone» (toll-free).

Best wishes,

The Feeding My Baby Study Team

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number.  The valid OMB control number for this information collection is 0584-0580.  The time required to complete this information collection is estimated to average 1 minute, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.