I hereby authorize____________________________________ to disclose to Alabama Cancer Care, LLC. my medical recordsand information pertaining to my medical history, physical history, services rendered or treatment of including, if any, psychiatric orpsychological information, infectious or contagious disease information, AIDS confidential information, and/or information about drugor alcohol abuse or treatment of the same.

By law, the HIPAA Privacy Rule prohibits Alabama Cancer Care, LLC. from disclosing your Protected Health Information (PHI) to anyonewithout your authorization, except for treatment, payment, and health care operations. This rule became effective April 14, 2003.

By signing below, I give Alabama Cancer Care, LLC. authorization to release my personal information as listed. I acknowledge thatI have received the attached Notice of Privacy Practices:

As you know, treatment cost can be very expensive. If you need any type of infusion therapy or chemotherapy, you may owe copays or co-insurance based on your insurance policy. We will verify your insurance and let you know prior to treatment what your costs will be. We have several non-profit foundations which help patients with their costs when funding is available and will do our best to help you with funding. In doing SO, we will need your information to fill out the applications. Please provide the following to allow us to assist you more efficiently.

You may be asked to provide proof of income in some situations such as tax forms, bank statements, or social security statements. The foundations will often ask for these to verify that you need the assistance. Your information is kept secure and confidential and is only shared with the foundation when asked for. It will not be shared with any other entity without your permission. Upon signing this form, you give us permission to apply on your behalf and share this information to obtain financial assistance for treatment purposes only.

*If you are not willing to share this information and you wish to be responsible for all costs, please sign below as refusal:

ALABAMA CANCER CARE, LLC. ACKNOWLEDGMENT OF RECEIPT OF ADVANCED DIRECTIVE MATERIALS

Alabama Cancer Care, LLC. ("ALCC") has, as required by the Patient Self-Determination Act, provided to me information concerning advance health care directives in the form of an information booklet (the "Booklet") on the date indicated below. I understand that the Booklet is provided for informational purposes only and describes in general terms the law and my rights with regard to advance health care directives.

I understand that the information contained in the Booklet is intended to serve only as a broad source of information on advance health care directives and the information is subject to change as the applicable law changes.

I acknowledge that I have received the information from ALCC regarding advance health care directives and agree that I have not received instructions from ALCC employees regarding completion of the advance health directive form, but have instead been advised to seek the counsel of my attorney or other advisor.

The Good Samaritan Drug Donation and Reuse Law allows our clinics to provide medication to uninsured patients through the use of donated, sealed and unused medications. Donating unused medications not only helps people in need but also reduces waste

and environmental impact. It's a compassionate way to make a difference!

I agree to donating any unused medications to ALCC for indigent needs: