This Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) Waiver (“Waiver”) allows individuals to upload personal health information (“PHI”) to The Field House Cancer Foundation’s website when applying for charitable assistance. For purposes of this Waiver, PHI includes medical records, test results, x-rays, insurance claims, diagnosis information, prescription information, and any other health data uploaded by the individual. The Field House Cancer Foundation may use, disclose, and retain the uploaded PHI only for purposes related to evaluating the individual’s eligibility and need for charitable assistance. The Field House Cancer Foundation will not use or disclose the PHI for any other purpose without the individual’s express written authorization. The individual has the right to review, request corrections to, and receive an accounting of disclosures of their PHI maintained by The Field House Cancer Foundation. The individual may revoke this Waiver by providing written notice to The Field House Cancer Foundation, but any PHI disclosed prior to revocation will not be subject to the revocation. The Field House Cancer Foundation will use appropriate safeguards to prevent unauthorized use or disclosure of the PHI. In the event of a breach of the PHI, The Field House Cancer Foundation will comply with applicable HIPAA breach notification requirements. This Waiver is governed by the laws of the State of Ohio, and any disputes concerning this Waiver will be resolved in a court of competent jurisdictions located in Franklin County, Ohio. This Waiver is effective as of the date the individual uploads PHI to The Field House Cancer Foundation’s website. By electing to upload your personal PHI to this website, you agree to be bound by the terms of this Waiver.