HIPAA Authorization Form
I, on behalf of my child or an individual to whom I provide guardianship (“Child”), authorize Dr. J. Savala (“MD”), in his sole function as a volunteer of Hillsborough School District (“School”), and along with OmeCare (together with MD, the “Providers”), to disclose my Child’s Covid-19 test results among themselves and to School with certain limitations listed below.
The purpose of this Authorization is to assist School in determining Child’s fitness for school during the COVID-19 outbreak. The specific information that may be disclosed under this Authorization includes Child’s name, contact information and any results of COVID-19 test performed to School or its affiliates.
I, on behalf of Child, may refuse to sign or may revoke this Authorization at any time and for any reason. If I, on behalf of Child, decline to sign the Authorization, Providers may use and disclose Child’s information for all purposes permitted by federal and state law.
My signed Authorization will remain in effect until I provide written notice that I, on behalf of Child, revoke this Authorization or in one year, whichever comes earlier. I may revoke this Authorization, on behalf of Child, by notifying Providers by email ( firstname.lastname@example.org ). The revocation will be effective immediately upon receipt of my written notice, except it will not have any effect on any prior action taken by School in reliance on this Authorization. In particular, the revocation will not impact School’s or Provider’s use or disclosure of health information already contained in Child’s Student file, medical staff credentialing or contractor file.
I understand that once Child’s health information has been disclosed to the authorized recipient, information potentially may be re-disclosed to others who may not be required to abide by this Authorization or who are not subject to the same federal or state laws governing the use and disclosure of Child’s health information.
I have read and understand the terms of this Authorization. By my signature, I authorize, on behalf of Child, Providers to use or disclose Child’s health information in the manner described above.