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Patient Marketing Authorization

Use this form to submit completed "Authorization for the Use and Disclosure of Protected Health Information (PHI) for the NEWS MEDIA, MARKETING AND ADVERTISING" forms.

Please submit one form per person as these forms will be tracked at the individual patient level.

Indicates a required field
Enter the date the patient signed the authorization form.
The Expiration Date defaults to 5 years from the Authorization Date.  If the patient specified a different expiration date on the form, then select that date.
Select the service line the authorization is intended for.
Please attach the completed authorization form.
Enter the Full Name and Email of the Employee submitting the form.
Hidden Fields

Sends to the request to the Marketing call center.
UTM