The Healthcare Market — Patient Enrollment & HIPAA Authorization

The Healthcare Market — Patient Enrollment & HIPAA Authorization

Enroll as a patient and authorize HIPAA-compliant information sharing with The Healthcare Market.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
State
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Programs of Interest
Current Medications
Preferred Contact Method
Best Time to Contact
HIPAA Authorization
By signing below, I authorize The Healthcare Market (thehealthcaremarket.com) and its representatives to use and disclose my health information as necessary for the purposes of care coordination, program enrollment, and related healthcare services. I understand that my information will be handled in accordance with HIPAA regulations, and that I may revoke this authorization at any time in writing. I acknowledge that my participation is voluntary and that I have read and understand this authorization.
E-Signature
I have read and agree to the HIPAA Authorization above.
I confirm that all information provided is accurate and that I am at least 18 years old.
Should be Empty: