SIRO

NOTICE

NOTICE FOR USE OF THE QUESTIONNAIRE

The following questionnaire will ask for medical information which will only be reviewed and handled by authorized personal according to the Health Insurance Portability and Accountability Act (HIPPA). The information provided will ease the generation of a patient profile information for helping the registration at the Staten Island Radiation Oncology Center.

I decline.

I agree to this notice that the information
       I provide will ease the registration at the
       Staten Island Radiation Oncology Center
       and that can be only be reviewed and
       handled by authorized personal.