AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION


 

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.


Full Name:


Current Address:

Physician Name:

Physician Phone Number:

Physician Email: 



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.

Initial

 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.

Initial

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.

Initial
Date:

Reset Signature