HIPAA Consent Form

Step 1
User Information

Step 2
Select Medication

Step 3
Authorization

Step 4
Confirmation

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Last 4 Digits of SSN*

Date of Birth*

Telephone

User Information

Welcome to HIPAAConsent.com, a secure and convenient way to submit authorization for appropriate individuals to provide you access to product and financial support services and also expedite patient care. You can easily sign and return your HIPAA consent form online.

Person must be 18 years or older to fill out this form. If the patient is under 18, please enter parent, caregiver, or guardian information.

If you need assistance, please reach out to AssistRx Support at 877-450-4412.

* Indicates a required field