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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION



 

 

 

  Today's Date:

 
   

  

I,                                                                                 , authorize the Cancer Foundation of the Florida Keys to obtain any, and all information pertaining to my diagnosis of cancer, and treatment of that disease from the Physician listed below.  I am applying for financial assistance, and understand that medical documentation is required by the Cancer Foundation of the Florida Keys.

 

Physician Name 

  

Physician
Phone Number


Physician E-Mail




1.  I understand that authorizing the disclosure of this health information is voluntary. I understand that my disclosure of information carries with it the potential for an unauthorized re-disclosure and that the information may not be protected by federal confidential rules.


2.  I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing, and present my revocation to the Chairman of The Grants Committee.


3.  I understand that if I refuse to sign, or, at any time revoke this authorization, I will become ineligible for financial assistance from the Cancer Foundation of the Florida Keys.

The completed form will be sent to:

1) The Cancer Foundation of the Florida Keys
2) Your Oncologist.

 

Date:  
Signature  

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