I, , am interested in participating in the 4th Angel Mentoring Program (the "Program") at the Cleveland Clinic. I understand that the Program is an innovative, interactive approach to cancer support. By agreeing to participate in the Program, I understand that my health information must be shared with Program staff to facilitate the match between myself and the Mentor(s) and/or Mentee(s) with whome I will work. I also understand that my health information will be shared with the Mentor(s) and/or Mentee(s) with whom I am matched and otherwise interact with through my participation in the Program.
By clicking the submit button, I hereby request and authorize Cleveland Clinic to release any and all health information that I submit or disclose to the Program to the Mentor(s) and/or Mentee(s) assigned to me and to other participants in the Program for purposes related to my participation in the Program. Such health information may include, but is not limited to, health information that I provide to staff of the Program and health information that I submit and disclose when I enroll and participate in the Program through use of its website.
This authorization will automatically expire upon my disenrollment in the Program or my revocation of this authorization, whichever occurs first. I may revoke this authorization at any time through written notice presented to the Program at 10201 Carnegie Ave., Cleveland, OH 44106. Any revocation will not apply to information that has already been released in response to this authorization. I understand and acknowledge that the health information disclosed may contain information regarding physical and mental fitness. HIS test results or diagnosis, treatment of AIDS/AIDS-related conditions, and/or alcohol/drug abuse, if I submit or disclose such information to the Mentoring Program.
I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on whether or not I sign this authorization. After my health information is released, my information may be re-disclosed and may no longer be protected by law.
To obtain a copy of this authorization, I must click this link to print. My ability to print a copy of this authorization expires once I leave this page.