I am providing the above information to Barbells for Boobs in connection with my request for financial assistance for a screening and/or diagnostic procedure previously prescribed by my doctor. I understand that Barbells for Boobs is under no obligation to grant my request and may grant or deny my request at its sole discretion. I further understand that Barbells for Boobs is not a treatment provider, that any screening or diagnostic service paid for by Barbells for Boobs will be performed by an independent breast center, and that Barbells for Boobs does not assist in the funding for treatment in the case of malignant diagnosis. All of the above information is true to the best of my knowledge and belief. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Barbells for Boobs to release any information required to fulfill services with a Barbells for Boobs chosen Healthcare Facility.