eHIPAA

For Questions and Inquires,
Please call the Harrow Cares Program
Phone Number: (866) 476-9462
Fax Number: (800) 686-7307
Hours of Operations:
8:00 AM – 8:00 PM EST
Mon. through Fri. not including holidays.

Your session has been inactive for a while now and will expire in two minutes, do you want to continue this session?

About This Form

You have expressed interest in the Harrow Cares program. Your privacy is important to us. In order for us to provide support services, we will need your authorization and consent to use your health information, called Protected Health Information (PHI), and also consent to share your information with your health plan and other companies that support your treatment.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

I am signing as parent or guardian (personal representative) of the patient.

Contact Information

Email Address *

Patient Cell #

555-555-5555

About This Form

Patient Information

Personal Representative Information

Contact Information