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By submitting an application to the Community Care Foundation for a financial assistance grant, I agree to the terms and conditions of the Community Care Foundation Financial Assistance Grant Program and, furthermore, I give consent to the Community Care Foundation to disclose and receive my personal health information (“PHI”) to and from my healthcare provider as listed on the grant application. This PHI consent is for the purpose of reviewing and determining financial assistance eligibility and my financial responsibility for my medical care. The PHI will be limited to my level of care provided by my provider, admission & discharge dates, and my financial responsibility for my medical care. I understand that information disclosed as a result of this authorization/consent may no longer be protected and could potentially be re-disclosed. However, such disclosure must be consistent with other State and federal Law which prevents the recipient from making any further disclosures without specific written consent of the person to whom the information pertains. I may revoke this authorization/consent at any time with written or verbal notice to the Community Care Foundation except as to information already released in reliance on this authorization/consent. This authorization/consent expires one (1) year from the date of this application.

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