Patient Training Use and Disclosure Authorization Form
Authorize the use and disclosure of patient training materials for educational purposes. Please complete all required fields to confirm your consent.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Clinic Name
*
Training or Session Description
*
Authorization Scope (describe what use/disclosure is authorized)
*
Recipient(s) or Departments Authorized to Receive Materials
*
Authorization Expiration (End Date or Duration)
*
Submit Authorization
Should be Empty: