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I hereby authorize the use and/or disclosure of my individually identifiable health information as described in this form. I understand this authorization is voluntary. I understand the released information may no longer be protected by federal privacy regulations and could be subject to redisclosure.

I hereby authorize a representative of the Helen G. Nassif Community Cancer Center, UnityPoint Health and/or Physicians’ Clinic of Iowa to use my name to accompany my statement on web, social media or other marketing materials.