In-Person Consultation

Authorization to Use or Disclose Protected Health Information

Please complete the form below to request your in-person consultation. Submissions for cancer second opinions will be reviewed daily for patient consult requests. 

Patient Information

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Medical Records to be Released FROM:

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Medical Records to be Released TO:

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Treatment Information

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The following information to be dislosed (please check):

Sensitive Information

Right to Revoke

Expiration

Redisclosure

Other Rights

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