HIPAA Marketing Authorization Form

HIPAA Marketing Authorization Form
Authorize the use or disclosure of your health information for marketing purposes. Please complete all required sections.
Patient Full Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Contact Email Address*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Recipient of Information (Person or Organization authorized to receive/use your health information)*
Description of Health Information to be Used or Disclosed (e.g., specific records, types of information)*
Purpose of Use or Disclosure (Describe the marketing activity or campaign)*
Expiration Date or Event (When does this authorization end?)*
MonthDayYear
Date
Relationship to Patient (if you are not the patient)
Signature of Patient or Authorized Representative*
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