FOR USERS IN ILLINOIS
Authorization to Share Information for Marketing Purposes
I hereby authorize Veriheal Telehealth Services and affiliated medical practices (“Veriheal”) to share my Protected Health Information (PHI) with Veriheal partners for the purpose of receiving marketing communications about medical cannabis products and services.
Details of Authorization:
Information to be Shared: My name, email address, and medical cannabis patient status.
Recipient: Veriheal partners, which may include licensed dispensary organizations or related service providers.
Purpose: To allow Veriheal partners to send me marketing emails about medical cannabis products, services, or promotions.
Remuneration: Veriheal may receive payment from its partners for sharing my information.
Expiration: This authorization remains valid until I revoke it in writing, unless otherwise limited by state law.
Right to Revoke: I may revoke this authorization at any time by sending a written request to Veriheal at [Veriheal Contact Address/Email]. Revocation will not affect actions taken before receipt of the request.
Voluntary Consent: I understand that agreeing this authorization is voluntary, and my treatment or services from Veriheal will not be affected if I choose not to agree.
Acknowledgment:
I have read and understand this authorization. I consent to the sharing of my PHI with Veriheal partners for marketing purposes as described above. I understand that once my PHI is shared, the recipient is responsible for protecting it under applicable laws, including any relevant state cannabis regulations.
