HIPAA Authorization HIPAA Authorization HIPAA Authorization The Cecil Specialty Clinic: Hep C, Hep B, HIV, PrEP, and STIs HIPAA AUTHORIZATION FOR USE/DISCLOURE OF INFORMATION, CONSENT TO RECEIVE TEXT MESSAGES OR EMAILS Name Name First Name First Name Last Name Last Name Middle name Middle Age DOB SS# Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Home Phone Cell Phone HIPAA Privacy & Security rules require your permission to use email or text messaging as a means of contact. Please check if you allow us to use email or text for: Test Results Appointment Reminders Medical Conditions To ensure that The Cecil Specialty Clinic is acting in accordance with your wishes, using your personal information with your authorization, and communicating with you in a manner with which you authorize, we ask you to sign this form to keep as copy of your written permission on file. I specifically authorize text messaging or email communication. I understand I am not required to authorize communications and can opt for other means of communication. Signature signature keyboard Clear Date Submit If you are human, leave this field blank.