The CancerExpertMD web site service offers to patients requesting additional clinical insight and explanations of diagnostic and treatment options in the subspecialty fields of Cancer and Blood disorders.
 

  
  INFORMATION AND RELEASE FORM
 		  
 

I, , hereby release to CancerExpertMD all reports including pathology reports, prior clinical summaries, lab reports and X-ray reports relating to the health of (Patient) to CancerExpertMD,and to its representatives,
CancerExpertMD Exeter #1, Boston, MA 02116
 

  
  Attending  Physician Name:  
  Phone: Fax:  
  Address  
  Email:
 		  
  I authorize the release of any and all medical information, including but not limited to mental health records, drug and/or alcohol abuse Records and/or HIV test results, if any, except as specifically stated:  
 
 		  
  This medical information may be used for the purpose of reviewing the diagnosis, the prognosis and the proposed treatment of my medical  condition in order to make comments, suggestions and insights into diagnostic approaches, prognosis and treatment options and for the purpose of publishing such review. I acknowledge that the publication of information  regarding such review and its contents is for the purpose of providing   a resource to patients and their physician, whether by journal or  Internet website, and will be published in a manner which preserves confidentiality and does not reveal my identity.
 		  
 

I acknowledge that any report concerning my medical care is only general in nature and cannot be specific to my actual case. Each and Every response by CancerExpert is general in nature and is intended to provide patients with details pertaining to their case which must be discussed with their physician.
 

  
 

This authorization is effective now and will remain in effect for one year.
 

  
  I understand I have the right to receive a copy of this Authorization.
I understand that my physician will receive a copy of the expert’s review.
 		  
  In the event that I am executing this authorization in a representative
capacity, I will accompany this authorization with such other
documentation as may be requested by CancerExpertMD or as may be
required by the laws of the State in which I reside.
 		  
  Dated (DD/MM/YYYY):   
  Patient Name:   
  Address:   
  Phone:   
  Email:   
  If not signed by the patient, please indicate relationship:  
    Parent or guardian of minor patient (to the extent minor could not
have consented to the care)		  
    Guardian or conservator of an incompetent patient  
    Beneficiary or personal representative of a deceased patient  
    Spouse or person financially responsible (where information solely
for purpose of processing application for dependent health care coverage)		  
     
 

Disclaimer: This opinion is based solely on the  review of those medical records provided to CancerExpert by the patient and/or treating physician. CancerExpert has not examined the patient nor is it  intent to do so in the future. Those opinions and comments rendered herein are intended for advisory purposes only. The Scope of the enclosed case review is in no way a substitute for a second consultation. The reports furnished are to be discussed with your treating physician.  It is within the sole discretion of the treating physician to determine the course, scope, and extent of treatment. It is expressly agreed and understood that CancerExpert review of those records provided and the rendering of any opinion based upon  review of those records provided do not create a physician/patient relationship.
 

  
     

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