The Leukemia & Lymphoma Society

Family Support Group
first time participant form
Are you a (please select one) *
Diagnosis *
Patient Confidentiality Agreement: *
To ensure patient privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) and to provide patients with control over what personal information is used and disclosed, I agree to have the above information released to The Leukemia & Lymphoma Society. *