Ironwood Cancer & Research Centers
Consent to Release Health Information
UHA MRN
UHA Patient ID
Patient Name:
First
M.I.
Last
Date
(MM/DD/YYYY)
I hereby authorize Ironwood Cancer & Research Centers and Urology Associates to use and disclose my personal health information to the individuals identified on this form.
Initials
I approve and understand that the staff at Ironwood may leave detailed messages on my voicemail.
Initials
Emergency Contacts:
Contact Name:
First
M.I.
Last
Telephone
(XXX) XXX-XXXX
Address
City
select
State
select
Zip
Relation
Emergency Contact?
Contact Name:
First
M.I.
Last
Telephone
(XXX) XXX-XXXX
Address
City
select
State
select
Zip
Relation
Emergency Contact?
Contact Name:
First
M.I.
Last
Telephone
(XXX) XXX-XXXX
Address
City
select
State
select
Zip
Relation
Emergency Contact?
I hereby authorize Ironwood Cancer & Research Centers and Urology Associates to use and disclose my personal health information to the individuals identified on this form.
I understand this may include information relating to communicable diseases, such as HIV/AIDS, STD, behavioral, and/or mental health, alcohol and/or drug abuse treatment, and genetic testing information, if any records exist.
I understand that the individuals identified on this form will be treated by Ironwood Cancer & Research Centers and Urology Associates as individuals involved directly in my care and as such Ironwood Cancer & Research Centers and Urology Associates will be allowed to release my personal health information to these individuals for the purposes of treatment, payment and healthcare operations.
I understand that I have a right to request and receive a Notices of Privacy Practices from Ironwood Cancer & Research Centers and Urology Associates.
THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.
I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original. I voluntarily sign this authorization, and I understand that my ability to obtain health care from Ironwood Cancer & Research Centers and Urology Associates will not be affected if I refuse to sign this authorization.
Patient Signature (Electronic)
Date/Time
(MM/DD/YYYY)
Personal Representative Signature (Electronic)
Relationship
Date/Time
(MM/DD/YYYY)