AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

I, __________________________________ [Print Name],
hereby authorize [Person/Entity/Physician to Provide/Release the Protected Health Information]:
Name of Person/Entity/Physician:________________________________Title:______________                               Address:___________________________________________________________________
Phone Number ___________________________________________________________

to release: _____my entire medical records; or
                 _____the following information (as specified):_____________________________ ___________________________________________________________________________
for the following time period: from  ___________ to ______________ 

to:	
                        ITA Partners 						            Secure Fax #:
                        1800 JFK Boulevard, 9th Floor 			215-569-0657
                        Philadelphia PA 19103
		
This authorization for use/disclosure is for the following purpose:  To enable ITA Partners to provide cancer management services to me.

This authorization shall be valid for a period of no longer than 12 months unless otherwise specified.  This authorization will otherwise expire on:__________________________ .  
     (Date, Event or Condition)    
I understand that I have the right to revoke/withdraw this authorization at any time, but that I must do so in writing to: Privacy Officer, ITA Partners, 1800 JFK Boulevard, 9th Floor, Philadelphia PA 19103.  I also understand that the revocation/withdrawal will be effective except to the extent ITA Partners has already taken action in reliance on my authorization.  
	
I understand that signing this authorization is voluntary and that signing this form is not a  condition of treatment, payment, enrollment or eligibility for benefits.   

I understand that, if the entity receiving the information is not subject to the Federal privacy regulations (also known as the HIPAA Privacy Rule), the information provided may be subject to re-disclosure and may no longer be protected by the HIPAA Privacy Rule governing confidentiality of protected health information.

I acknowledge that ITA Partners is a business associate as such is defined under the HIPAA Privacy Rule.  ITA Partners complies with the HIPAA Privacy Rule as it applies to  business associates.

__________________________________________________Date: ______________________
Signature of Patient or Authorized Representative 
__________________________________ (Print Name)

__________________________________ (If signed by an Authorized Representative, representative's relationship to patient)


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