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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 Illinois Department of Public Health through TAAG Genetics Corp. and its subsidiaries, to:
Me via email, even though email is not a completely secure means of communication.
Me via SMS, even though SMS is not a completely secure means of communication.

State of Illinois
I also understand and agree to the following:

I may refuse to provide this authorization.

I may revoke this authorization at any time in writing emailed to TAAG Genetics Corp. at contact_US@taag-genetics.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If this authorization has not been revoked, it will terminate one year from the date of effectiveness below.

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.