I am requesting access to PreventionGenetics’ myPrevent electronic portal (portal). I understand that information I have access to within the portal will contain Personal Health Information (PHI). I attest that I am an employee of the covered entity listed above and I am authorized to use the PHI in order to perform my job duties. I further attest that as an employee of the covered entity listed above, I am requesting access for the purpose of ongoing treatment of patients, payment and/or healthcare operations. I will not access, disclose, or request action that violates HIPAA. I understand that PreventionGenetics reserves the right to terminate access based on restrictions or other change that adversely affects or violates HIPAA.

I affirm that the covered entity listed above allows transfer of patient results to this email domain.