First Name
下の名前だけ
이름 입력 (성 제외) Number only - No space, no ( , no -
番号だけで（”－”なし、スぺースなしで）
숫자만 입력

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HIPAA Disclosure

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby voluntarily authorize the disclosure of my protected health information, including any and all test results and vaccination records, provided by
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.
Result via email and, or SMS, even though email is not a completely secure means of communication.

I also understand and agree to the following:
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at testsierrabiolab.com, except to the extent that action has been taken in reliance on this authorization.
If this authorization has not been revoked, it will terminate one year from the date of effectiveness.
I have a right to request and receive a copy of this authorization.
Any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient, and any redisclosure may not be subject to HIPAA.

This authorization is effective immediately upon clicking the button “Agree and continue” on this authorization page.

I agree to the Authorization for Disclosure of Protected Health Information.