By signing in the box below I am stating the following: "I authorize and request that my COVID Test results be disclosed to, and used by, appropriate WesternU officials, including but not limited to appropriate officials in the WesternU’s Student Employee Health Office, in order to encourage a safe campus, workplace, and learning environment, and to enhance the safety of WesternU’s students, employees, and visitors"
This HIPAA Release is valid for 1 year from the date of submission of this form.