Neighbors Helping Neighbors Authorization Form Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Applicant's Account/ Reference Number(Required)I hereby authorize West Central Georgia Cancer Coalition to:(Required) obtain from the following release to the following Name/Business Name:(Required) Add RemoveThe following documents/information from the records pertaining to services received.Date of Service MM slash DD slash YYYY The records are required for the specific purpose of:I understand that any information released to the West Central Georgia Cancer Coalition will be handled confidentially in compliance with all applicable federal laws. I have read and understand the nature of this release. Signature of Applicant/Applicant’s Designated Representative(Required) First Last Date(Required) MM slash DD slash YYYY West Central Georgia Cancer Coalition First Last Date MM slash DD slash YYYY Δ
