HIPAA Release Form

I hereby authorize the use or disclosure of my protected health information as described below:

Main Street Drug & Boutique is authorized to disclose my contact information (HIPAA Information) to Medi Pharma Care aka: MPC Patient Outreach; who is in possession of a BAA with said location and is an agreed vendor of safety. The purpose of this use or disclosure is updating the Patient Outreach Software for use in marketing or patient awareness campaigns. I understand that my information will not be sold, shared or exploited and will be used in accordance with HIPAA regulations. I understand the terms and conditions. I understand that I can opt-out at any time and it will not effect my relationship with Main Street Drug & Boutique

I hereby agree to be contacted by Main Street Drug & Boutique.