HomePatient Forms & PoliciesHIPAA Marketing Authorization
Optional · HIPAA
HIPAA Marketing Authorization
Optional. Authorizes Bayou City Breastfeeding to use specific information in marketing or educational materials.
The full HIPAA Marketing Authorization is provided as a PDF.
Use the Download PDF button above to read the complete document. You’ll review and sign this form through Jane, our practice-management system, when you schedule a visit.
If you’d like a copy of an earlier version, or if you have a question about anything in this document, email admin@bayoucitybreastfeeding.com. We won’t begin treatment until you’ve had the opportunity to review the documents and ask questions.
What this document covers
The HIPAA Marketing Authorization is an optional form. By signing it, you specifically authorize Bayou City Breastfeeding to use information you identify, for example, a written testimonial, a photograph, or your name in a story, in marketing or educational materials such as the website, social media, or printed handouts. You may revoke a marketing authorization in writing at any time; revocation does not affect uses already made in reliance on the authorization.
How it fits with the other forms
This document is entirely optional. You can become a client and receive every service we offer without signing it. It is here only for people who want to opt in.
Questions before you sign?
Email admin@bayoucitybreastfeeding.com or call (281) 305-0411. We’re happy to walk through any section with you before your first visit.
Ready to schedule?
When you book a visit, Jane sends you the intake documents and the consent for the service you’re scheduling. Request Appointment or call (281) 305-0411.