IBCCP Authorization to Obtain Information

I hereby give consent to release the following information(Required)

Clinic Report

Medical Reports

Laboratory Report

Other

Other, specify

Regarding:

Client's Name(Required)

Client's Address

Date of Birth(Required)

To: Agency Name & Address, ATTN: Illinois Breast & Cervical Cancer Program

Agency Name*(Required)

Agency Address

Phone

I agree to release said provider, its employees, agents and representatives from any liability, loss, damage, costs, claims and/or cause of action connected with released information pursuant to this authorization.

I understand I have the right to revoke this consent at any time by giving written notice. Unless I revoke sooner, this consent will expire one (1) year from the date of signature.

I understand and agree that a photostatic copy or facsimile of this consent will be valid as the original, even though such copy does not contain the original writing of my signature.

Signature(Required)

Date (Signature)(Required)

Witness(Required)

Date (Witness)(Required)