HHID Authorization

As the legal owner of my (or my child’s or ward’s) health information, I authorize The Medical Internet for Humanity to:

Create a Human Health Identifier (HHID) for me (or my child or ward).
Collect and compile relevant personally identifiable information and all documented health information related to me (or my child or ward).
Safely store it all for my secure access and portability, at no cost to me or those I designate as my (or my child’s or ward’s) healthcare providers.

By submitting the following information, I grant these permissions to The Medical Internet for Humanity, who will operate in the strictest adherence to HIPAA privacy requirements, and I permit them to contact me as part of the process.

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Thank you. Your authorization has been submitted.

Full Name (of patient)

Date of Birth (patient’s) – Note: YYYY/MM/DD

Phone

I affirm the validity of this information as: (required)

My own.

My child's or legal ward's.

I hereby authorize The Medical Internet for Humanity to safely collect and securely store my (or my child’s or my ward’s) Personal Health Information.

Additional notes (optional)