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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 Altera Laboratory Services.
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I may refuse to provide and or revoke this authorization at any time in writing emailed to Altera Laboratory Services at testalterabiolab.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If this authorization has not been revoked, it will terminate one year from the date of effectiveness.
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Any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient, and any redisclosure may not be subject to HIPAA.

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