HIPAA Authorization for Marketing Communications

Patient Name Date of Birth

Authorization

Name of Entity Authorized to Use or Disclose Information Recipient of Disclosed Information Description of Health Information to be Used/Disclosed Purpose of Use/Disclosure

I understand the information may include records relating to treatment for substance use, mental health, and/or HIV/AIDS.

Expiration

This authorization will expire on (date or event):

Signature

Signature of Patient or Personal Representative Date If signed by Personal Representative, describe relationship to patient