I am providing the above information to Mammograms In Action, Inc. in connection with my request for financial assistance for a mammogram previously prescribed by my doctor. I understand that Mammograms In Action is under no obligation to grant my request and may grant or deny my request at its sole discretion. I further understand that Mammograms In Action, Inc. is not a treatment provider, that any mammogram or diagnostic service paid for by Mammograms In Action, Inc. will be performed by an independent breast center, and that Mammograms In Action, Inc. 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 Mammograms In Action, Inc. to release any information required to fulfill services with a Mammograms In Action, Inc. chosen Healthcare Facility.