Health Intelligence (HI) Marketing For People That Can't Spell HIPAA

HIPAA Disclosure: Provider needs to sign a HIPAA compliance form. Once the email being used is a HIPAA Compliant email it can not be changed for the provider and the patient's protection. This document will be provided once provider accepts forthcoming terms.

Provider Name *

Clinic Name *

Providers Address *

Email *

NPI Number *

Phone *

Key Admin Staff Name *

Admin Email *

HIPAA Disclosure: Provider needs to sign a HIPAA compliance form. Once the email being used is a HIPAA Compliant email it can not be changed for the provider and the patient's protection. This document will be provided once provider accepts forthcoming terms.