For Toy Store
Authorization to disclose protected health information for marketing and media purposes.
I am the legal guardian and have permission to sign on behalf of the patient. I understand that this service Toys for Hospitalized Children is providing is a free service and I am opting in.
I hereby authorize Toys for Hospitalized Children and its employees to use and disclose certain protected health information ("PHI"), as defined by the Health Insurance Portability and Accountability Act ("HIPAA".)
The PHI that may be used and disclosed by Toys for Hospitalized Children and its employees include ALL of the following: individual's name, name of treatment facility, condition, home address, hometown city, age or birth date.
Toys for Hospitalized Children and its employees may use and disclose that information for public advocacy, outreach, media relations, social media, education, and research.
I confirm I am over 18 years of age, and to the best of my knowledge, I am legally authorized to represent the interests of the patient.