Authorization for Use and Disclosure of Health Information - v.7.23

AUTHORIZATION: By signing this Authorization, I agree that the health information of the person named below (the “Person”) may be used and disclosed as follows:

REASONS THE PERSON’S HEALTH INFORMATION MAY BE USED AND DISCLOSED:  The  Person’s Health Information (as defined below) may be used and disclosed to: test the Person for infectious disease; limit the spread of infectious disease among the workforce, students, families, and other people involved with the school district in which the Person is enrolled or employed, or in which the Person’s child is enrolled (the “District”); provide wellness and health-related resources and services to the Person; and confirm the Person is eligible to participate in District-related events.

PEOPLE WHO MAY USE AND DISCLOSE THE PERSON’S HEALTH INFORMATION: 

1. MVML, Inc. and other laboratory services providers arranged by Healthy Campus, LLC (collectively, “LSPs”), and Campus Physicians of California, P.C., Rume Medical Group, Inc., and other health care providers arranged by Healthy Campus, LLC (collectively, “HCPs”) may use and may disclose the Person’s Health Information to each of the following Authorized Recipients:

 

• The District, its agents and employees;
• Healthy Campus, LLC;
• The LSPs; and
• The HCPs.

 

2. Each of the Authorized Recipients may share and communicate with each other about the Person’s Health Information received from an LSP or HCP.

THE  PERSON’S HEALTH INFORMATION:  This Authorization applies to the Person’s name, demographic information (such as gender and age), contact information (such as address, phone number and email address), test results, medical evaluations, medical diagnoses, treatment, care plans, and participation and/or enrollment in health plans (“Person’s Health Information”).

EFFECTIVE PERIOD: This Authorization is valid from today’s date until the later of, as applicable, the last day that the Person is enrolled in a school operated by the District, the last day that the Person’s only or youngest child is enrolled in a school operated by the District, or the last day that the Person is employed by a school operated in the District, unless I revoke (cancel) it before that time.

RIGHT TO REVOKE AUTHORIZATION: I may revoke (cancel) this Authorization at any time by sending an email to support@campusclinic.org. I understand that, if I do revoke the Authorization, anyone who already received the Person’s Health Information may keep using it for the reasons stated above (they do not have to give it back). I also understand that some disclosures of the Person’s Health Information are allowed by law without an Authorization, and may happen even if I revoke the Authorization (for example, to diagnose and treat disease).

NO CONDITIONING: I understand that no treatment, payment, enrollment, or eligibility for benefits will be conditioned on whether I sign this Authorization.

ACKNOWLEDGEMENT OF POSSIBLE FURTHER DISCLOSURE:  Information disclosed under this Authorization may not be further used or disclosed unless another authorization is signed, or the use or disclosure is specifically required or permitted by law.  If the Person’s Health Information is further used or disclosed, it may no longer be protected by state or federal law.

COPY OF AUTHORIZATION: I am entitled to receive a copy of this Authorization after I sign it.

I understand, agree to, and am voluntarily signing this Authorization.

 

My Name

My Signature

Today’s Date

 

If Person is under the age of 18, the Person’s parent or guardian must sign below.

I understand, agree to, and am voluntarily signing this Authorization on behalf of my minor child.

 

 

Person’s Name

My Relationship to Person

Person’s Date of Birth