Description of Information to be disclosed: The COVID-19 PCR SALIVA TEST RESULTS (“COVID Information”) of the above named individual.
Purpose of Disclosure: PARTICIPATION IN NEW JERSEY SCHOOLS COVID-19 SCREENING TESTING PROGRAM and SCHOOL ATTENDANCE
This authorization will expire one year from the date on which it was signed.
This authorization permits the release of COVID information of the above-named individual to the above-named Recipient on an ongoing basis for however many COVID tests such individual undergoes before the expiration of this authorization.
- I understand that any disclosure/release is bound by the Health Insurance Portability and Accountability Act of 1997 (HIPAA) 45 C.F.R. pts 160 & 164; and re-disclosure of this information to a party other than one designated above is forbidden without written authorization on my part, unless required or permitted under law or regulation.
- I understand that the NJDOH and its Testing Partner have no ability to prevent re-disclosure of my COVID information by Recipient.
- Signing this authorization is voluntary. I understand that I have the right to revoke this authorization at any time, except to the extent that NJDOH and its Testing Partner have already acted in reliance on it. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the school nurse or whomever the school designates in writing to receive such notice.
I have read this form and all of my questions have been answered to my satisfaction. By signing this form, I acknowledge that I have read, understand and accept all of the above.