This authorization applies to any information governed by the Health Insurance Portability and Accountability Act of 1996, 42 USC Section 1320d et seq., and 45 CFR Parts 160-164, and implementing regulations, as amended from time to time (“HIPAA”), and/or by California’s Confidentiality of Medical Information Act, California Civil Code Section 56 et seq., and implementing regulations, as amended from time to time (“CMIA”), and/or by requirements of the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g; 34 CFR Part 99, and implementing regulations, as amended from time to time (“FERPA”). Specifically, this authorization complies with the valid authorization requirements of 45 CFR Section 164.508(c) and California Civil Code Section 56.11 and 34 CFR Part 99, Subparts B, C, and D.
AUTHORIZATION: I authorize Campus Clinic LLC, Covid Clinic, Inc, MedLab2020 Inc (or other designated Laboratory Services Provider (“LSP”)), Campus Physicians of California, P.C., and Driven Care, Inc (or other designated Health Care Provider (“HCP”)) and District to use and disclose the protected health information described below. References herein to “my” information shall mean: (i) information relating to me, if I have consented to this authorization on behalf of myself; or (ii) information relating to my child or other person, if I have consented to this authorization as parent of my child or legal guardian of such other person.
EFFECTIVE PERIOD: This authorization for release of information covers the period from: today’s date to the end of 2038.
EXTENT OF AUTHORIZATION: I hereby authorize the release of my visit, medical evaluations, medical diagnosis, the results of the COVID-19 of other Infection Test and my personal information related to the aforementioned tests, diagnosis, visits, or procedures (“My Medical Information”). My Medical Information may be used by the HCP, LSP, Covid Clinic, Campus Clinic, and District for the Intended Purpose of providing access to additional resources and services, confirming eligibility to participate in school or school related events, and controlling the spread of infectious diseases on campus. I also hereby authorize District to access and use my personal information related to any Notice of Positive Result to help to prevent the spread of COVID-19 or other infection to the District workforce and students, and their respective families, with the limitation that District will keep confidential any Notice of Positive Result (including my related personal information) and use or disclose that information only as specifically authorized herein. Any information I share through social media or otherwise that set forth herein is shared voluntarily, and I release Campus Clinic, Covid Clinic, MedLab2020, the LSP, the HCP and District from liability under the HIPAA and the CMIA for the information I share.
RIGHT TO REVOKE AUTHORIZATION: I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
VOLUNTARY RELEASE: I understand that no treatment, payment, enrollment, or eligibility for benefits will be conditioned on whether I sign this authorization.
ACKNOWLEDGEMENT OF DISCLOSURE: I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I also hereby authorize Campus Clinic to use and disclose my Information to send me information about products and services provided by Campus Clinic or its affiliates that may be relevant or useful to me. Campus Clinic may receive remuneration for such disclosure. (Email firstname.lastname@example.org if you would like to opt out of such marketing now or at any time in the future).