Lotus Forms Samples (HIPAA Consent Form)

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Accesses:	27
NavCode®:	1WP1001YF
Creation date:	7/14/09
Updated date:	7/14/09
Provider:	IBM

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This portlet is supported by IBM through the normal Software Support channels. To report a problem with this sample, entitled Customers should call 1-800-IBM-SERV to report a problem with this Lotus Form Sample.

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Item Details that you are requesting information for:-

Name

NavCode

Provider

The fields indicated with an asterisk (*) are required to complete this transaction; other fields are optional.

Salutation

First name *

Last name *

E-mail address *

Phone

Position or title

Company

(Enter full company name, not abbreviations.)

Address

City

State/Province

Zip/Postal code

Country *

Message *

In order to fulfill your request for further information, the information you provide in this form will be forwarded to the IBM Business Partner. Thank you for your interest.

By clicking "Submit" you agree that IBM may process your data in the manner indicated above and as described in Privacy.

Description:

Online form required to comply with HIPAA standard privacy security transactions; provides patient consent regarding how the provider may use and disclose protected health information about the patient.

This form includes the following features:

Date Selector - The user can type a date in the entry field or select a date by clicking the calendar icon.
External Link - Opens an external link in a separate window.
Click-Wrap Signature button - The user's digital signature using Click-Wrap signing technology.

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This sample requires IBM Lotus Viewer 3.5, Web Forms Server 3.5 or higher.

English

Worldwide

Healthcare

Software
- IBM Lotus products
  - IBM Lotus Forms
- Operating system

English

Small & medium business

IBM Lotus Forms

Straight-through processing

Supported

IBM Developed: This item works with the respective IBM products and services offerings.

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IBM

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Lotus Forms