Patient Authorization & Release of Liability
The requestor may use the information authorized for the purpose of determining how best to serve the patient listed above based on his/her needs. I understand that I may revoke this authorization at any time.
I hereby release Rock Cancer C.A.R.E. from any/all legal liability that may arise from the use of this information.
- I confirm that the above information is complete and true, to the best of my knowledge.
- I authorize Rock Cancer C.A.R.E. to use the information for the purpose of determining how best to serve the patient listed above based on his/her needs.
- I understand that I may revoke this authorization at any time.
- I hereby release Rock Cancer C.A.R.E. from any/all legal liability that may arise from the use of this information.
- I understand that I have the right to receive a copy of this authorization upon my request. (Civil Code Section 56.11)
RELEASE AND WAIVER OF LIABILITY AGREEMENT
- IN CONSIDERATION of being permitted to utilize the services and programs of Rock Cancer C.A.R.E., the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Rock Cancer C.A.R.E., Inc., their directors, officers, employees, and agents (hereinafter referred to as “releases”) from all liability to the undersigned, his or her personal representatives, assigns, heirs, next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned or such children, whether caused by negligence of the releasees or otherwise while the undersigned is participating in any program affiliated with or receiving services provided by Rock Cancer C.A.R.E.. Any dispute between the parties relating to this Agreement or its interpretation will be resolved by binding Arbitration, in accordance with the commercial arbitration rules of the American Arbitration Association in California. The arbitrator(s) will be limited to awarding compensatory damages and will have no authority to award punitive, exemplary or similar type damages. I
UNDERSTAND THAT I AM GIVING UP THE RIGHT TO A JURY COURT TRIAL.
- THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasee or otherwise while utilizing the services of Rock Cancer C.A.R.E. or participating in any program affiliated with Rock Cancer C.A.R.E.
- THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER and INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
- THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD
HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur
due to the undersigned, participating children and any personal representatives, heirs and next of
kin’s, use of Rock Cancer C.A.R.E. services or participating in any program affiliated with Rock
Cancer C.A.R.E. whether caused by the negligence of the releasees or otherwise.
THE UNDERSIGNED HAS RED AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY, and further agrees that no oral representations, statements of inducement apart from the foregoing written agreement have been made.