Care Team Application

I hereby acknowledge that the Medical Information above has been completed to the best of my knowledge and hereby permit the patient (“Applicant”) to participate in the respite beach vacation offered by Waves of Grace and acknowledge that the Applicant may participate despite the medical limitations listed above.

I authorize the use and disclosure to Waves of Grace of protected health information about Patient as described below:

Information that may be used/disclosed: All protected health information relating to Physician’s assessments of: (a) whether Patient is medically eligible for Waves of Grace services; and (b) if so, whether his/her desired respite beach vacation is medically appropriate. In addition, Physician is authorized to fill out, sign and provide to Waves of Grace forms that Waves of Grace may require, including forms relating to Patient’s medical eligibility, the requested beach vacation and medical consideration relating thereto.

Persons authorized to use/disclose the information: The Physician identified, as well as his/her authorized representatives.

Persons authorized to receive the information: Employees or other authorized representatives of Waves of Grace.

Purpose for which information will be used/disclosed: To enable Waves of Grace to obtain: (a) Physician’s assessments regarding whether Patient is medically eligible to have a respite beach vacation granted by Waves of Grace and, if so, whether the requested vacation is medically appropriate; and (b) pertinent information relating thereto.

Expiration date/event: This authorization expires once Patient’s respite beach vacation has been granted by Waves of Grace or a final determination has been made that Patient is not eligible to receive a respite beach vacation.

Statements required by HIPAA: In accordance with the Health Insurance Portability and Accountability Act, I acknowledge the following:

a. I understand that I may revoke this authorization at any time by so notifying Physician in writing, except to the extent that action has already been taken in reliance on the authorization;

b. I understand that if the person/entity that receives the information described above is not a healthcare provider or health plan covered by federal privacy regulation, such information will no longer be protected by these regulations and could potentially be re-disclosed by the recipient.

I hereby warrant and represent that the information provided to Waves of Grace is accurate. I consent to be contacted by Waves of Grace via phone or e-mail at the numbers/addresses provided by me or my oncology team in regard to a Waves of Grace respite beach vacation. If granted a respite beach vacation, I will be traveling at my own risk. If selected a recipient of Waves of Grace, I recognize the travel risk and acknowledge that there are certain risks of physical injury, including death, damages, property damage, or loss which I may sustain as a result of traveling to and from as well as during my stay at a beach property. I agree to waive and relinquish all claims that I may have for injuries or damages, as a result of participating in a beach vacation through Waves of Grace and its officers, agents, servants, employees, other volunteers, and affiliates as well as the property owners.

I give Waves of Grace and professional photographer used for the free sunset beach session permission to use my photographs on social media, website, and marketing.