Patient’s Full Name Oncologist’s Name
Address Patient’s Date of Birth
City, State Zip Code Patient’s Telephone Number

I hereby authorize use or disclosure of protected health information about me as described below.

  1. The following specific person/class of personality/facility is authorized to use or disclosure information about me:_______________________________________________________________________________________________________________
  2. The following person (or class of persons) may receive disclosure of protected health information about me:

  3. ARCTIC COLD CAPS
    4300 Haddonfield Rd
    Pennsauken, NJ 08402

  4. The specific information that should be disclosed is (please give dates of service if possible):Information pertaining to the cancer diagnosis, chemotherapy orders and treatment plan and ongoing coordination of patient schedules to coincide with Arctic Cold Caps treatment as needed.
  5. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it,    and would then no longer be protected by federal privacy regulations.
  6. I may revoke this authorization by notifying _______________________________ in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
  7. My purpose/use of the information is for Arctic Cold Caps Therapy .
  8. This authorization expires on _____________, 201___, OR upon occurrence of the following event that relates to me or to the purpose of
    the intended use or disclosure of information about me:  _____________________________________.THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.

     

Signature of Individual
(The person about whom the information relates)		 Date of Individual’s Signature Date of Birth or Social Security Number
Signature of Guardian* or Personal Representative of Patient’s Estate Date of Guardian’s/Personal Representative’s Signature Description of Authority to Act for the Individual

A copy of this completed, signed and dated form must be given to the Individual or other signator.