|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.
- The following specific person/class of personality/facility is authorized to use or disclosure information about me:_______________________________________________________________________________________________________________
- The following person (or class of persons) may receive disclosure of protected health information about me:
ARCTIC COLD CAPS
4300 Haddonfield Rd
Pennsauken, NJ 08402
- 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.
- 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.
- 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.
- My purpose/use of the information is for Arctic Cold Caps Therapy .
- 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.