Registration for the prostate cancer awareness wellness fair Survey

What is a Prostate Specific Antigen (PSA)? A PSA test is a simple blood test that measures the level of protein produced by the prostate gland.

1.Full Name

2.What is your phone or email address?

3.What is your current age?

4.Would you be interested in getting screened ?

Yes

5.Do you currently have a primary care provider? if no, please comment "NO", If so, please list provider information below.

6.I AUTHORIZE THE RELEASE OF MY PHI FROM:
UNC Lineberger Comprehensive Cancer Center LCCC and Cumberland County Department of Public Health

I AUTHORIZE THE RELEASE OF MY PHI TO:
share content from events in order to promote, educate, and provide feedback from events and awareness.

I understand that:
My PHI may be used for education offered or directed by my UNC Health physician or provider in any format or forum
which may include but not be limited to publication in written or online media, books or journals, classroom instruction
and/or medical training at UNC Health or other educational institutions, and/or at local national and global conferences
or other professional or educational events.

I further authorize the release of the following information which may be included in my PHI:
☐ Mental Health/Psychiatric Treatment
☐Alcohol or Substance Abuse Treatment
☐ STD/HIV/AIDS Treatment(s) or Test(s)
☐ Genetic Testing

Authorization for Education, Fundraising and Marketing / Public Relations Purposes - Photo,
Video and Other Protected Health Information (PHI)

I will not receive remuneration for releasing my PHI for the purpose(s) listed above.
I hereby release UNC Health and its affiliates and employees from any and all liability that may arise from the release
of my PHI as authorized by this form.
I have the right to revoke this Authorization at any time if I do so in writing and address it to the person or institution
named above. The revocation will not apply to any information already released as a result of this Authorization.
I may refuse to sign this Authorization, and I cannot be denied or refused treatment if I refuse to sign and my refusal
to sign this Authorization will not affect my treatment, payment, enrollment or eligibility for benefits or the quality of
care I receive.
Once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by the
federal medical privacy laws and could be re-disclosed by the person or agency that receives it.
This Authorization shall not have an expiration date and shall remain in effect unless and until I provide my written
revocation made to the UNC Health office, facility or health care provider listed above.
My signature below indicates that I am giving permission for the use and disclosure of the PHI described above.

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