Thank you, but I believe this service is unnecessary.
Thank you, but I believe this service will not be effective in protecting privacy.
I have no need for this service, but I will pass on the information.
YOUR PLANS
I plan to use the Healthcare Services form. Approximately how many?
I plan to use the Financial Services form. Approximately how many?
I plan to use the Home Health Agencies form Approximately how many?
The first three persons/entities I intend to give the Privacy Declaration form to are:
Doctor/Dentist
Doctor/Clinic
Radiology/Physical Therapy Center
Financial Institution
Insurer/HMO
Home Health Agency
Government agency
Health plan
Medical Device Supplier
Pharmacy
Credit Bureau
Pharmaceutical website
Employer
Attorney
Hospital/Surgical Center
School
Nursing Home
Health care practitioner
YOUR CONTACT INFORMATION
We hope that our "FOR THE RECORD" Medical Privacy Project has provided you with useful tools and information to better protect your privacy. We would like you to have a chance to get to know our organization better. Find several options below.
Email subscriptions:
CCHC has four (4) email lists. Choose which you would like to be on and we will place your email address on the appropriate list. You may unsubscribe at any time and we will not add you to list that you do not ask to be on:
The CCHC HEALTH eNEWS (a twice-weekly news briefing on national health care and medical privacy issues, plus notices of regulations available for public comment). Subscribe instantly.
National press releases - CCHC news releases of national interest.
Minnesota press releases - CCHC news releases pertaining only to Minnesota.
Minnesota legislative reports - sent primarily during the MN legislative session.
My email address is:
Newsletter:
CCHC's bi-monthly newsletter, the CCHC Insider Report, is mailed by the U.S. Post Office primarily to supporters and persons who have shown a recent interest in CCHC. CCHC's activities, and insights are shared along with eye-opening quotes and indepth reporting on news, federal reports, and major events not discussed in the CCHC HEALTH eNEWS. Suggested donation is at least $25.00 to cover production and mailing costs. Contribute to CCHC.
Yes, I would like to receive the CCHC Insider Report. My contact information is below.
Yes, I am pleased to support the work of CCHC with a tax-deductible contribution of $
Your Contact Information (optional):
The information you provide below will be useful to use, both in building support for our organization, and in showing the range of supporters for medical privacy initiatives. Since your personal privacy is very important to CCHC, please be assured that the information you share will not be disclosed, released or sold by CCHC. If you allow us to, we may however use it to direct certain pressing policy and legislative information in your direction, depending on where you live, and what kind of insurance policy you have.
Name:
Title:
Address:
City:
State:
Country:
Zip Code:
Email:
Work Phone:
Home Phone:
Fax:
Insurance Status (check all that apply):
Medicare
Employer-sponsored coverage
Medicaid
Individual insurance policy
High-risk State plan
Christian Newsletter
Retiree Policy
Children's Health Insurance Plan
HMO
Medical Savings Account
High-deductible Policy
Family policy
Spouse's Policy
Uninsured
Partial Insurance: some immediate family members are insured; others are not insured
