Authorization for Use and Disclosure of Health Information
I authorize the laboratory performing my coronavirus test(s) to release my health information to the company hiring me to perform work, and any agents working on behalf of that company to facilitate a safe working environment, including, but not limited to, Vaheala LLC.
My health information includes the results of my SARS-COV-2 (novel coronavirus) test(s), the type of test(s) performed, my test identification number(s), and the date and location of my test(s).
My health information will be used to facilitate decisions about whether I should go onsite to work. If I have any other testing performed by the laboratory (not related to the coronavirus), that information will not be disclosed.
I acknowledge that I have a right to revoke this authorization at any time by submitting my request in writing by emailing firstname.lastname@example.org
, except to the extent that the laboratory has taken action in reliance on my authorization. Because my coronavirus test(s) are being performed for the company hiring me to perform work, I also understand that my ability to be tested is conditioned upon my agreement to this authorization.
I can obtain a copy of this authorization by emailing email@example.com.
I understand that my health information disclosed pursuant to this authorization may be redisclosed by the recipient and no longer protected by applicable federal or state law.
By clicking “I Accept”, I authorize the use and disclosure of my health information as outlined above. My authorization will expire three years from the date of my acceptance.