AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

TO: All doctors, dentists, physicians, hospitals, dermatologists, or other health care professionals treating the undersigned.

I, (above name) residing at (above address), authorize you to release and discuss any and all medical records and medical information that you have for me in your possession regarding my medical condition and my medical treatment, including but not limited to, my medical history, my medical treatment, your findings regarding my medical condition, records of consultations that I have had, records of medication prescribed for me, x-rays taken of me, my radiology reports, and hospital, medical, and billing records to The Field House Cancer Foundation.

This authorization is intended to be an unlimited, full, and complete Authorization for the release of any and all protected medical information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Medical Records Access Act, as amended, and under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, emergency services, financial and administrative transactions, and business associates. A covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning of authorizations in 45 CFR 164.508(b4) applies.

It is understood that the person to whom this Authorization is given has my permission to use and disseminate this information in his or her sole discretion.

1. Expiration. This authorization expires at my death.

2. Right to Revoke. I have the right to revoke this authorization by signing and dating a written statement revoking this authorization, and it shall become effective on delivery to you. If this authorization is revoked, any person or entity acting in good faith in reliance upon it and lacking actual knowledge of its revocation shall be held harmless.

3. Redisclosure. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected by this rule.

4. Administrative Provisions. I revoke any prior authorizations I have made to disclose health information that are inconsistent with this authorization. This document shall be governed by Michigan law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub L No 104-191, and the Medical Records Access Act, MCL 333.26261 et seq. However, I intend it to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Michigan law and HIPAA to interpret and determine the validity and enforceability of this document.

5. Voluntary. I am providing this authorization voluntarily and have not been required to give it to obtain treatment. I am at least 18 years old and of sound mind. 6. Durable power. This authorization shall not be affected by my disability or incapacity. The authority of my agent shall be exercisable notwithstanding my later disability or incapacity or later uncertainty as to whether I am alive. 7. Photographic Copies. Photocopies or facsimile reproductions of this signed authorization shall be treated as original counterparts. Photographic or facsimile reproductions of this executed authorization to disclose health information (with reproduced signatures) may be made and delivered by me or my agent and may be relied upon by any person to the same extent as though the copy were an original.