STEP 1: HIPAA Authorization for the Disclosure of Health Information

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

Use your mouse or finger to draw your signature above
Date/Time
:  

STEP 2: Record Upload

Are you uploading a vaccination card or a negative test result?*
Type of Vaccine*
Type of Vaccine - Copy

Each attendee must create their own registration to receive an email stating the submission has been verified.

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

We will contact you via email if we have any questions or concerns about your submission.
Date of First COVID-19 Vaccine Dose *
Date of Second COVID-19 Vaccine Dose
Date of Third COVID-19 Vaccine Dose
Date of Fourth COVID-19 Vaccine Dose
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

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. 

Date Test Was Taken*
Result Date*

STEP 3: IHP Consent, Terms , and Conditions

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

Use your mouse or finger to draw your signature above
Date Signed*

If you encounter any problems during the submissions process, please contact verify.support@ihphysicians.com and enter your event name in the subject line. 

Confirmation

Attendee has submitted a valid Vaccination or Test Result record.*
Verified Date