9HEALTHMARKETING AUTHORIZATION FORM

Agenda

• WHAT is this and WHY is this at 9Health Fair sites?

• How to pass this out

• How to answer participant questions

• How to collect it

• FAQ’s

Marketing Authorization

Form

• To be given to on-site participants with their Participant Registration Form.

• Online participants will receive this form only if they ask for it.

How to answer participants’ questions:

Have extra non-medical volunteers floating around registration

Have them review this video

Have them review the actual form the morning of the fair

How to collect it:

How to collect it, continued: Extra Form Check volunteers Participant keeps top, colorful copy 9HF retains bottom, yellow copy Put “signed” copies in designated white envelope

This envelope goes to Cashier Supervisor at the end of the fair

Put “unsigned copies” in designated white envelope This envelope goes back to 9Health Fair in supply

boxes at the conclusion of your fair

FAQ’s:1. Are participants required to sign this form?

2. Do I have to sign this form in order to get other tests done at a 9Health Fair?

3. Can I be contacted with health information without signing this form?

4. Will my private health information be given to any other organizations?

5. How long does this authorization last?

6. How do I cancel this authorization?

FAQ’s, continued:7. What does this statement mean:

Information used or disclosed pursuant to this Authorization may be re-disclosed by the individual and no longer be subject to HIPAA.

8. For whom is the “Personal Representative” signature line? Why would they need to sign this form?

QUESTIONS?

CONTACT YOUR9HEALTH FAIRLIAISON