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BY SUBMITTING THIS FORM:
I acknowledge that I am voluntarily providing my personal information to Loma Linda University Health – Community-Academic Partners in Service (CAPS). 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 – Community-Academic Partners in Service (CAPS) directly at (909) 651-5011 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.