I agree that the information and documents provided in connection with this application are complete and accurate. I agree that I have documentation to support the information submitted in the application if requested.
I agree to immediately inform the Cancer Resource Foundation if my income or insurance status changes during the course of my participation in this Program. I understand that my information will be used by the Program sponsor, Cancer Resource Foundation, for purposes of determining my participation in, and administering the Program, which may
include contacting me as well as my Doctor/Healthcare Provider, office/hospital staff, insurer (public/provider) or others.
I understand a representative from the Program, may contact me for additional information. I authorize and consent to release identifiable information about me including medical, financial and insurance records and information as required for participation in the program. My authorization includes release of information related to my medical conditions and treatment, if required. I understand that identifiable information about me will be kept confidential and will not be further used or disclosed except to administer the Program, or as required by law. I understand that information I authorize to be disclosed may be re-disclosed and is no longer protected by Federal privacy regulations. I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document.
I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization however this authorization is required for eligibility in this grant assistance program. This consent shall be in effect until revoked by the patient.