STEP 1: HIPAA Authorization for the Disclosure of Health Information 

By signing this Authorization, I acknowledge that I have read and understand this Authorization. Further, I authorize the disclosure of the information set forth herein in accordance with the terms of this Authorization.

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Date/Time*
:  

STEP 2: COVID-19 Test Record Upload

Each attendee must submit their own COVID-19 test record labeled with their full name and date of test to receive record verification.

Name*
Arrival Date:*
Date of Birth (mm-dd-yyyy)*
Gender*
Address*

All pictures of self-administered tests must have your first and last name, and date of test to be verified.


 If you are submitting a COVID-19 test result record from a clinic, the record submitted must include your first and last name, date of test, type of test, and the clinic name. 


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File uploads may not work on some mobile devices.
Each attendee must submit their own COVID-19 test record labeled with their full name and date of test

STEP 3: IHP Terms & Conditions

By signing below, I acknowledge and agree that I have read the Agreement and agree to all terms contained therein.

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Date/Time*
:  

If you encounter any problems with uploading your submission, please contact verify.support@ihphysicians.com and enter your event name in the subject line.

Test Result

Result*
Date