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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.

Download PDF Form

Patient Information

Name of MD

Diagnosis

Treatment Information

Please select all that apply:

Self

Continuity of Care / For Another

Disability

Legal

Insurance

The following information to be dislosed (please check):

Abstract

Discharge Summary

History and Physical examination Consultations, including psychiatric evaluations

Operative report or procedure reports

Emergency Department Record

Laboratory reports, including drug screens

Radiology or x-ray reports

Interdisciplinary records (progress notes)

Medication lists and documentation

Nursing notes

Physician orders

Sensitive Information

I understand that the information in my records may include information relating to sexually transmitted diseases. Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) infection. It may also include information about behavioural or mental health services or treatment for alcohol and drug abuse.

Right to Revoke

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 via mailing or faxing to one of the locations listed above. I understand that revocation will not apply to information that has already been released based on this authorization.

Expiration

Unless otherwise revoked, this authorization will expire on the following date or when the following event or condition occurs; if I do not specify an expiration date, event, or condition, this authorization will expire in 60 days.

Redisclosure

I understand that any disclosure of information carries with it the potential for redisclosure and the information may not be protected by federal confidentiality rules.to the terms & conditions

Other Rights

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to ensure treatment. Research participation requires a separate authorization by the patient. I understand that I may inspect or obtain a copy of the information to be used or disclosed. If I have any questions about disclosure of my health information, I can contact Cincinnati Cancer Advisors by calling the number listed above.

Signature of Patient or Legal Representative (hold and drag mouse to sign)

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