Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.Parts 160 and 164)
I, First Name* Last Name* authorize DNA is the Way to disclose my protected health information, DNA test report, with name of person to see report* for the purpose of designing a fitness plan for me. I understand that my information will be confidential and will not be shared with any other person.
If you are unable to e-sign this form you may print it out, sign it and scan it back to my email address, email@example.com
Or you may print, sign and mail it to
DNA is the Way c/o Laura Fuller
19897 Beverly Park Road
Estero, Florida 33928