HIPAA Release and Compliance Form

I, the undersigned, authorize OncoSupport to use and disclose my health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) for the purpose of matching me with a personalized support group. I understand that my information will only be shared with the clinical professionals involved in the OncoSupport program and will not be shared with any third parties without my consent, except as required by law.

By signing below, I authorize the release of my health information to OncoSupport for the purpose of matching me with a personalized support group and providing related services. This includes:

• My diagnosis
• Treatment history and current treatment plan
• Emotional and mental health needs relevant to cancer care
• Any additional health-related information that will be relevant for matching me to the appropriate support group

I understand that I have the right to revoke this authorization at any time by providing written notice to OncoSupport. However, any disclosures made prior to the revocation will remain valid. I understand that the revocation will not apply to actions already taken based on this authorization prior to my written notice.

OncoSupport will maintain the confidentiality of my health information as required by HIPAA and will use appropriate measures to protect my personal data. All information shared will be handled in accordance with OncoSupport’s privacy policies. Specifically:

• Only authorized individuals will have access to my health information.
• My health information will not be used for purposes other than matching me with a support group or related services.
• OncoSupport will ensure that all personal and health data is securely stored and transmitted.

I authorize OncoSupport to share my health information with healthcare professionals involved in the support group program, including but not limited to:

• Physicians, nurses, counselors, and other healthcare providers who may be involved in my treatment or care.
• Other individuals or entities that are responsible for assisting with my support group participation.

I understand that there are potential risks associated with the disclosure of my health information, including the possibility of unintended disclosure to unauthorized individuals or the possibility that my information may be lost or compromised due to technical failure. OncoSupport will take reasonable precautions to protect my health information.

I acknowledge the following rights under HIPAA:

• Right to Access Information: I have the right to request copies of my health information and to inspect or amend my medical records.
• Right to File a Complaint: If I believe my privacy rights have been violated, I have the right to file a complaint with OncoSupport or the U.S. Department of Health and Human Services.
• Right to Request Confidential Communications: I can request that my health information be communicated to me by alternative means or at alternative locations.

By signing this form, I acknowledge that I have read and understood the purpose and conditions of this HIPAA release. I voluntarily authorize the release of my health information to OncoSupport for the purposes outlined above. I understand that I may ask questions and request clarification regarding this form at any time.