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<td> </td>
<td valign="top">Date of Birth</td>
<td> </td>
<td>Description of Personal Representative's Authority</td>
</tr>
</table></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
</table>
</div>
<div id="LastPageInForm" runat="server" align="center" style="page-break-before:always;">
<table width="700" border="0" cellpadding="0" cellspacing="0" bgcolor="ffffff">
<tr>
<td align="center"><font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION
- HANDLE ACCORDING TO MSKCC POLICY</font> </td>
</tr>
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="700" cellpadding="1" cellspacing="0">
<tr>
<td width="350" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" alt="" width="80" height="80" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
</span><span class="blackBoldTextLarge"><br>
HIPAA Patient Authorization<br>for Post-Treatment Follow-up</span><br> </td>
<td width="325" align="center" valign="bottom" > <table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
<td align="right">
<% =patientMRNLabel %>
</td>
<td align="left"><strong>
<% =patientMRN %>
</strong>
<% =patientDOB %>
</td>
</tr>
<tr>
<td colspan="1" align="right">
<% =patientNameLabel %>
</td>
<td colspan="1" align="left"><strong>
<% =patientLastName %>
,
<% =patientFirstName %>
<% =patientMiddleName %>
</strong></td>
</tr>
<tr>
<td align="right" valign="top">
<% =patientAddressLabel %>
</td>
<td align="left" valign="top">
<% =patientAddress1 %>
<% =patientAddress2 %>
<% =patientCity %>
<% =patientState %>
<% =patientPostalCode %>
</td>
</tr>
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
</tr>
<tr>
<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient
Identification</td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="100%" border="0" cellspacing="0" cellpadding="14">
<tr>
<td><br>
<table width="670" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="blackBoldText">May we contact you regarding your post-treatment progress
using the internet? We would send you email notifications and ask you to report your progress online via secure web forms.</td>
</tr>
<tr>
<td height="30" align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
No </td>
</tr>
<tr>
<td height="30"> </td>
</tr>
<tr>
<td class="blackBoldText">May we contact you regarding your post-treatment progress by telephone?</td>
</tr>
<tr>
<td height="30" align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
No </td>
</tr>
<tr>
<td height="30"> </td>
</tr>
<tr>
<td class="blackBoldText">Check the box below if you prefer that we <strong>DO NOT</strong> contact you.</td>
</tr>
<tr>
<td height="30" align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Please do not contact me for post-treatment follow-up.</td>
</tr>
</table>
<br> <br> <br> <table width="670" border="0" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr>
<td height="30" align="center" class="blackBoldTextLarge">CONTACT
INFORMATION </td>
</tr>
<tr>
<td height="24"><em> The contact information
of the patient or personal representative completing this
form should be filled in below.</em></td>
</tr>
<tr>
<td height="30"><table width="670" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="60" height="23" align="right" valign="bottom">Address </td>
<td width="240" height="30" class="FormInnerRowBottomBorder"> </td>
<td width="40"> </td>
<td width="60" align="right" valign="bottom">Telephone </td>
<td width="210" class="FormInnerRowBottomBorder"> </td>
<td width="60" valign="bottom"> Daytime</td>
</tr>
<tr>
<td height="23"> </td>
<td height="30" class="FormInnerRowBottomBorder"> </td>
<td> </td>
<td> </td>
<td class="FormInnerRowBottomBorder"> </td>
<td valign="bottom"> Evening</td>
</tr>
<tr>
<td height="23"> </td>
<td height="30" class="FormInnerRowBottomBorder"> </td>
<td> </td>
<td colspan="3" valign="bottom"><table width="270" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="64" align="right"> </td>
<td width="96">Best Time to Call </td>
<td width="120" class="FormInnerRowBottomBorder"> </td>
</tr>
</table></td>
</tr>
<tr>
<td height="23"> </td>
<td height="30"> </td>
<td> </td>
<td height="23" align="right" valign="bottom">Email </td>
<td class="FormInnerRowBottomBorder"> </td>
<td valign="bottom"> </td>
</tr>
<tr>
<td colspan="6"> </td>
</tr>
</table></td>
</tr>
</table>
<br>
<br>
<table width="670" border="0" cellspacing="0" cellpadding="4">
<tr>
<td>ANY INFORMATION YOU PROVIDE VIA THE INTERNET OR EMAIL MAY
NOT BE SEEN BY YOUR DOCTOR OR YOUR DOCTOR'S STAFF. IF YOU
FEEL ILL OR THINK YOU NEED TO SPEAK WITH YOUR DOCTOR OR A
MEMBER OF YOUR DOCTOR'S STAFF BEFORE YOUR NEXT APPOINTMENT
YOU CANNOT USE THIS SYSTEM TO CONTACT YOUR DOCTOR. YOU MUST
USE THE TELEPHONE OR ANOTHER METHOD TO CONTACT YOUR DOCTOR.
IF YOU CANNOT REACH YOUR DOCTOR OR A MEMBER OF HIS OR HER
STAFF, YOU SHOULD CONTACT THE NEAREST EMERGENCY ROOM FOR ASSISTANCE.
</td>
</tr>
</table>
<br>
<br> <table width="670" border="0" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr >
<td height="30" colspan="5" align="center" class="blackBoldTextLarge">SIGNATURE</td>
</tr>
<tr >
<td width="10" height="40"> </td>
<td width="660" height="40" colspan="4"><em>I have read this
form and all my questions about this form have been answered.
By signing below, I acknowledge that I have read and accept
all of the above.</em></td>
</tr>
<tr >
<td> </td>
<td colspan="4"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="300" height="30" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="300" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td>Signature of Patient or Personal Representative</td>
<td> </td>
<td>Date</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td colspan="3" class="blackBoldTextSmall"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="300" height="30" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="83" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="167" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td valign="top">Print Name of Patient or Personal
Representative</td>
<td> </td>
<td valign="top">Date of Birth</td>
<td> </td>
<td>Description of Personal Representative's Authority</td>
</tr>
</table></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
</table></td>
</tr>
</table>
<br>
<br>
<br> <table width="670" border="0" cellspacing="0" cellpadding="0">
<tr>
<td align="center"> <p>Thank you very much for your cooperation.</p></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
</table>
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