From RECP Form, 2021
U.S. Department of Justice AUTHORIZATION TO RELEASE
Civil Division MEDICAL AND OTHER INFORMATION
To: Arizona Tumor Registry
Colorado Cancer Registry
Wyoming Tumor Registry
New Mexico Tumor Registry
Nevada Statewide Cancer Registry
Utah Cancer Registry
I hereby authorize the release of any and all medical and other information in your possession, custody, and control to representatives of the Radiation Exposure Compensation Program (RECP), Department of Justice, relating to the individual whose name appears on line 1 of this form. This data is required to determine eligibility for compensation under the Radiation Exposure Compensation Act, 42 U.S.C. § 2210 note (2006).
For the RECP to request medical information on your behalf, you must SIGN THIS FORM.