Information Release Release of Information Newsletter First NameLast NameI hereby give my permission for Cancer Services, its principals, employees, public benefits advocates and agents to obtain from any source including, but not limited to, hospitals, physicians, agencies, medical providers, social service agencies and others, to photocopy, review and release all records and/or financial information concerning me, at the discretion of Cancer Services, to any and all public and/or private agencies or other person for the purpose of evaluating, applying for and attempting to obtain public or private benefits for me and/or my immediate family. I understand and agreeCancer Services will make every effort to protect my identity and personal information and that only the information necessary will be disclosed. The question of privacy between my attending physician or physicians, any institution, Cancer Services and myself is hereby waived. I understand and agreeI allow Cancer Services to use photographic, audio, video, digital, or other representations of my image for promotional or other uses. I do I do notThis consent and release is subject to revocation by me or my legal representative at any time upon written notice to the Patient Advocate Director, Cancer Services, 3175 Maplewood Ave., Winston-Salem, NC 27103. A photocopy or telefacsimile (or copy by other electronic means) of this executed Information Receipt or Release shall be valid as the originally executed document.DateSignature Sign Here Our mission is “Enhancing Health, Life, and Survivorship.”Submit Form
