HIPAA Funnel

Agent dashboard

After creating an account, enter the newest code from your email, then return here and sign in. Email verification confirms your address; you can then complete the short setup for your new public form.

HIPAA Funnel

Dashboard

One-time setup

Create your secure intake form

Tell us how prospects should see you. Your private form address has already been reserved.

Your name Agency or business name Notification email Verified sign-in email Public phone Optional

Your prospect form link

The anonymous address does not contain your name or email. It becomes active when setup is complete.

Free plan: three first-time retrievals per week. New submissions are always accepted.

Available submissions

Viewing starts a 24-hour grace period. Delete the server copy after you save what you need.

Retrieved submission

Client

Contact and acknowledgment

Answers to review

Negative and unselected questions are hidden here so the details needing attention are easier to scan. The complete submission remains available in the JSON download.

Public form settings

The insurance questions and sharing notice are locked to the published template.

Your prospect form link

Open form

This anonymous address is assigned automatically and does not expose your name or email.

Organization name Representative name Public phone Notification email Verified sign-in email Brand color

Logo

No logo uploaded.

Headshot

No headshot uploaded.

Thank-you title Thank-you message Next-step message Website HTTPS

Thank-you business card Personalized message Public phone Logo Headshot Website link

Supported placeholders: {{FIRST_NAME}}, {{REPRESENTATIVE_NAME}}, {{ORGANIZATION_NAME}}

Submission notifications

Email alerts are always sent to your verified sign-in email. SMS is optional and contains no prospect information.

Private mobile number Verification code

By checking this box, I agree to receive transactional SMS alerts from HIPAA Funnel by Last Dash Media, LLC when a secure form submission is ready. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not required to use HIPAA Funnel.

Plan and retrievals

Free plan · three first-time retrievals per UTC week. Reopening a retrieved submission does not count again.

Submissions remain available even after the retrieval allowance is reached. Paid-plan checkout will appear when Stripe prices are configured.