I authorize the Lung Health Coalition to obtain a copy of my previous records related to my lung health. This may include, but is not limited to, biopsy, pathology, surgical and other relevant reports from prior providers for comparison with current or future lung cancer screening studies. This authorization permits the release of confidential health care information to the Lung Health Coalition for the sole purpose of tracking screening results, follow-up needs, and potential support services.


I understand that this authorization is effective immediately and remains in effect for 18 months from the date of signature, unless revoked in writing. I also understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.


Type of Study: Low-Dose CT Lung Cancer Screening

Reason for Release: Data Collection

I understand that the information released is for the specific purpose stated I understand that the information released is for the specific purpose stated above. Any other use of this information without the patient's written consent is prohibited.