Pass It on Request Form

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HANFORD HEALTH INFORMATION NETWORK 2400 Smith Tower 506 Second Avenue PASS IT ON REQUEST FORM Your Telephone No. Please take a moment to write down the names and addresses of Hanford downwinders that you believe might like to receive inforination from the Network. You may want to include family members, former neighbors and co-workers, and others you knew when you lived within the three-state area. Please include people who still live in Washington, Oregon and Idaho, as well as those who now live in other states. Also, please complete the Limited Waiver of Confidenti;ility forni on the back of this sheet which gives your perinission to let people know that we are sending the information at your suggestion. Without this signed waiver, we will not be ithle to mail materi;ils to the people you suggest. Thank Please print clearly. (Please remember to complete the back of this sheet, the Limited Waiver of Confidentiality)

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HANFORD HEALTH INFORMATION NEWORK RESOURCE CENTER Limited Waiver of Confidentiality - Specific Purpose Under federal law (Public Law identifier number 101-510; 104 Stat.1834), information that identifies persons who have paFticipated in Hanford Health Information Network information and referral programs is automatically protected as confidential. Personal and identifying information which you provide to the Network - including names, addresses, telephone numbers, radiation exposure and medical information - is protected as confidential unless that confidentiality is waived by you or your legal representative in writing. This means that the Hanford Health Information Network (HHIN) will not make private information you provide to us available to anyone other than those directly involved in Network services. However, you may waive this confidentiality for specific purposes, if you so choose. In order for the Network to release any personal or identifying information about you, HHlN must have a written waiver from yo’u authorizing the use of your information If (and only if) you wish to authorize the Hanford Health Information Network to use and disclose personal information which may id,entify you, for the specific purposes set forth below, please complete this form, sign it, and return it to the HHlN representative indicated Personal Information to be used and disclosed: my name only I authorize HHlN to use this information for the purpose of: sending Network information fo my I am signing this document to authorize the Hanford Health Information Network to use and disclose the information described above for the purposes specified above. Print Name Print Telephone Number Print Street Address, City, State and Zip Code PLEASE COMPLETE THIS FORM AND RETURN IT TO: , Questions? Please call 1-800-959-7660 for more information