AUTHORIZATION TO RELEASE INFORMATION
By signing below, I hereby authorize the use or disclosure of any provided health or personal information to any board member, employee, contractor, or other professional retained by, or working with, Helping AMC Families Incorporated (the “HAMCF”). I certify that I am either (a) an applicant seeking assistance from Helping AMC Families Incorporated or (b) have the legal power and authority to release such health and personal information on behalf of the applicant. Further, I certify that I am mentally competent to make medical and/or financial decisions for the applicant. I understand that the information in the applicant’s/my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that I/the applicant have the right to revoke this authorization at any time. I understand that if I/the applicant revoke this authorization I/the applicant must do so in writing and recover and destroy all copies of this document that I/the applicant have previously distributed. I understand the revocation will not apply to information that has already been released in response to this authorization.
I understand that authorizing the disclosure of this health, financial, or other related information is voluntary. I can refuse to agree to this authorization. I understand I/the applicant may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.
I understand that HAMCF has sole discretion in determining whether to grant me any assistance and that, by submitting this application or seeking assistance from HAMCF, HAMCF does not in any way guarantee, agree, contract, or promise to me that I will be offered or receive any assistance of any kind from HAMCF.
I grant Helping AMC Families Incorporated the right, in their sole discretion, to use, copy, reproduce, publish, distribute, publicly display, or otherwise make sure of my name, image, and likeness, in any and all media now known or hereafter devised, including but not limited to print, online, digital, video, social media, and in connection with all websites or services offered by Helping AMC Families Incorporated, from this date and continuing forever, without any compensation to me. I waive any and all claims, actions, causes of action, suits, or damaged related to rights of privacy, rights of publicity, copyright, trademark, or other personal, intellectual property, or moral rights arising out of or in connection with the use of my name, image, or likeness by Helping AMC Families Incorporated.
I release, indemnify, and forever hold harmless Helping AMC Families Incorporated and their respective officers, directors, agents, members, representatives, employees, and volunteers from and against any claims, liabilities, judgements, damages, actions or cause of action, including but not limited to, personal injury, death, or damage to or loss of properly, relating to or arising out of my submission of my application, decisions made of discretion exercised by the charity, including but not limited to, the offering or not offering to me of the assistance requested by my application or any other assistance, and the manner in and means by which any assistance to which I am offered or granted is administered by the Helping AMC Families Incorporated.
Lastly, I hereby permit Helping AMC Families Incorporated to use and retain the health, financial, personal, or other related information provided to Helping AMC Families Incorporated in Helping AMC Families Incorporated sole and absolute discretion. I give Helping AMC Families Incorporated authorization to speak with any other AMC/medical travel assistance programs.