BY SUBMITTING THIS FORM:I acknowledge that I am voluntarily providing my personal information to Loma Linda University Health – Center for Health Disparities and Molecular Medicine. I understand that in order to keep my health information private, I will abstain from using this form to provide details about my medical condition or that of the individual I am requesting information for. I will limit the amount of information shared on this form to only my contact information in order to receive the requested information. I understand that I may contact Loma Linda University Health – Center for Health Disparities and Molecular Medicine directly at (909) 558-8777 in case I need to discuss confidential or private information. I further understand that I may be contacted by a representative from LLUH in response to my inquiry via telephone or mail. I understand LLUH will not respond via email when communicating confidential or private information.
909-558-8777 909-558-0196 firstname.lastname@example.org
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