Authorization form; marketing, fundraising and sale of PHI policy

Granite City Family Dental · Policy set version 1.0 · Effective November 1, 2026

Authority: 45 CFR 164.508; 164.501 (definitions of marketing and sale of PHI); 164.514(f).

Part A — Authorization for use or disclosure of protected health information

Use this form whenever a use or disclosure is not permitted without authorization: marketing, sale of information, most releases of psychotherapy notes, releases to employers, life insurers, attorneys (other than by subpoena), researchers, and any other purpose the patient requests. In Minnesota this form also serves as the consent required by Minnesota Statutes 144.293 when its elements are completed.

Authorization for Use or Disclosure of Protected Health Information

Granite City Family Dental · 412 2nd Street South, St. Cloud, MN 56301 · 320-555-0142

Patient name: ______________________________________ Date of birth: ______________

Address: ______________________________________ Phone: ______________

1. I authorize Granite City Family Dental to use or disclose the following information about me (describe specifically; for example "visit notes from January to March 2026", "immunization record", "entire record"):

______________________________________________________________________________

☐ This authorization includes mental health information [ ] alcohol or drug treatment information [ ] HIV or sexually transmitted infection information [ ] genetic information

2. To be disclosed to (name, organization, address, phone or fax):

______________________________________________________________________________

3. Purpose of the disclosure: [ ] At my request [ ] Other: ____________________________________

4. This authorization expires on ______________ (date) or upon ____________________________ (event). If no date or event is given it expires one year from the date signed. 5. My rights. I understand that:

I may revoke this authorization at any time by writing to the Privacy Officer, Janelle Okafor, at the address above. Revocation does not apply to information already released in reliance on this authorization.
Granite City Family Dental will not condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this form, except where the treatment is research-related or the sole purpose of the service is to create information for a third party.
Information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law.
I may inspect or obtain a copy of the information to be disclosed, and I am entitled to a copy of this form.
If this authorization is for marketing and Granite City Family Dental receives payment from a third party for the communication, that payment has been disclosed to me: [ ] Not applicable [ ] Yes, Granite City Family Dental receives payment from ____________________.
If this authorization is for the sale of my information, I understand Granite City Family Dental will receive payment in exchange for it.

Signature of patient or personal representative: ______________________________________ Date: ______________

If signed by a personal representative, name and description of authority (parent, guardian, power of attorney): ______________________________________

Office use. Received by: ______________ Date: ______________ Identity and authority verified: [ ] Yes Logged for accounting of disclosures: [ ] Yes

Part B — Marketing, fundraising and sale of PHI policy

1. Definitions

Marketing is a communication about a product or service that encourages the recipient to purchase or use it, other than (a) communications about our own health-related products or services, case management, care coordination, or treatment alternatives, so long as we receive no financial remuneration from a third party for making them, (b) face-to-face communications, and (c) promotional gifts of nominal value. Sale of PHI is a disclosure of PHI in exchange for direct or indirect remuneration. Fundraising is a communication to raise funds for our own benefit.

2. Marketing

Marketing communications require the patient's written authorization (Part A). If the communication involves financial remuneration from a third party, the authorization states that fact.

We send patient newsletters, service announcements or requests for online reviews. Each communication is reviewed by the Privacy Officer before release to confirm it is either (a) about our own services with no third-party remuneration, (b) face-to-face, or (c) covered by a signed authorization. Review requests contain no health information and are sent only to patients who have not opted out. Responses to online reviews never confirm that the reviewer is a patient or mention any detail of care.

We do not accept payment from any third party to communicate with patients about that party's products or services. Any proposal to do so is referred to the Privacy Officer.

3. Fundraising

We do not use patient information for fundraising. If that changes, the Notice of Privacy Practices is amended to say so and an opt-out mechanism is implemented before the first communication.

4. Sale of PHI

PHI is not sold or otherwise disclosed in exchange for remuneration without the patient's written authorization stating that remuneration is involved, except as permitted by 45 CFR 164.502(a)(5)(ii) (for example, public health disclosures, treatment and payment, a sale of the practice, or cost-based fees for copies).

5. Online reviews and social media

No workforce member may post, confirm or respond to anything identifying a patient on social media or review sites, including replying to a patient's own review. All review responses are generic and approved by the Privacy Officer.

Violations are handled under the Sanction Policy and, where PHI was disclosed, assessed under the Breach Notification Policy.

6. Documentation

Authorizations, opt-outs and marketing approvals are retained for six years.

Approval

Approved by: Dr. Maria Lindqvist, Owner

Signature: ______________________________________ Date: ______________