Northwestern Medical Faculty Foundation, Inc.


AUTHORIZATION TO RELEASE INFORMATION TO OTHER PATIENTS

I give permission to Northwestern Medical Faculty Foundation ("NMFF") to release my name, address and other contact information (and, in doing so, the fact that I may have received medical services from NMFF and from NMFF's Urology Department) to current and prospective patients of the NMFF Urology Department who request to speak to other patients. I understand that this is being done so that I might be a reference to NMFF's Urology Department and its physicians. NMFF will not disclose any specific information about my treatment to the other patients unless I give further consent.

I understand that I may refuse to sign this form and that my choice about whether to sign this form will not change the way NMFF treats me. NMFF will not deny care to me if I refuse to sign. Nor am I obligated to communicate with anyone who contacts me. I also understand, however, that once NMFF releases my information, federal and state privacy laws may not protect the information. I also know that NMFF cannot be responsible for how the other patients use my information.

This authorization will last for 10 years after the date that I sign this form. If I change my mind before that time, I must let NMFF know in writing, and NMFF will no longer share information with the other patients (although NMFF will not be able to take back any disclosures that it made while this authorization was in effect).

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