Consent to Service and Acknowledgment of Privacy Practices:
The treatment or service provided under this authorization and consent shall include the following: COVID-19 Nasal swab testing (“the Service”). I, the undersigned, agree and acknowledge that I have been apprised of the risks of receiving the Service and that I knowingly and voluntarily consent to receiving the Service from Mobile-Med Work Health Solutions, Inc. I also agree and acknowledge that I have been offered a copy of the current Notice of Privacy Practices utilized by Mobile-Med Work Health Solutions, Inc.
Consent for Disclosure of Protected Health Information
HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
As Required by Health Insurance Portability and Accountability Act (HIPAA), 45 CFR 160, 164
I, the undersigned, hereby authorize Mobile-Med Work Health Solutions, Inc. to use and/or disclose the protected health information described below to the party listed as Employer, above (without regard to whether I am an employee of said Employer or not).
This authorization covers the disclosure of results from the Services described above by Mobile-Med Work Health Solutions, Inc., at any time. I hereby authorize the release of protected health information consisting of the notice that I have received the Services, as well as the results of the testing included in the Services and any related health information gathered during the conduct of my testing or my interaction with Mobile-Med Work Health Solutions, Inc. I also consent to the release of any information required to bill for the services, as may be required by Employer, or by any health insurance plan or program that I am a part of. All of the foregoing information may be released to the Employer. In addition, I understand that the results of any testing which demonstrates that I may have a communicable illness may be reported to public health authorities in accordance with HIPAA regulations. I acknowledge that information shall not be disclosed and shall be limited from disclosure in ways or for reasons not authorized herein.
This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, determination about my ability to safely work or return to work, or other purposes that I may direct. This authorization shall remain in effect until I deliver a written revocation of this authorization to Mobile-Med Work Health Solutions, Inc, via certified mail, return receipt requested, received at 2101 Forest Avenue, Suite 220A, San Jose, CA 95128. I am not authorizing the release of mental health or psychotherapy records, alcohol or drug testing records or HIV test results. I understand that I have 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. If I do not take action to revoke this authorization sooner, this authorization shall automatically terminate on December 31, 2030.
I understand that my receipt of the services will be conditioned on whether I sign this document, as the care referenced above is being provided solely for the purpose of providing protected health information for disclosure to a third party.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient in accordance with federal or state law.