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In-Person Consultation

Authorization to Use or Disclose Protected Health Information

Please complete the form below to request your in-person consultation. Submissions for cancer second opinions will be reviewed daily for patient consult requests. 

Patient Information

Medical Records to be Released FROM:

Medical Records to be Released TO:

Treatment Information

Please select all that apply:
The following information to be dislosed (please check):

Sensitive Information

Right to Revoke



Other Rights

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