Consent to Service, Acknowledgment of Privacy Practices, and Release of Liability:
The treatment or service provided under this authorization and consent shall include the following: administration of SARS COV-2 COVID-19 vaccine via intramuscular injection ("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. I understand and agree that the Service is being provided as a benefit to me through the California Department of Public Health, that I am not being required to undergo the Service and that I am undertaking the Service as a voluntary, informed choice. I agree to release, indemnify and hold harmless Mobile-Med Work Health Solutions Inc., from any claims or damages arising out of or relating to the Service.
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 as described below.
This authorization covers the disclosure of the conduct of the Services described above by Mobile-Med Work Health Solutions, Inc., at any time. I acknowledge that information shall not be disclosed and shall be limited from disclosure in ways or for reasons not authorized herein. I hereby authorize the release of protected health information consisting of the notice that I have
received the Services and any related health or demographic information gathered during the conduct of the Services or my interaction with Mobile-Med Work Health Solutions, Inc. as follows:
- I consent to the release of this information to public health authorities in accordance with HIPAA regulations for purposes of complying with vaccine registration regulations.
- In the event that I require any emergency medical services as a result of the administration of the Services, I further agree to the disclosure of this information to other healthcare providers who may provide care to me.
I acknowledge that information shall not be disclosed and shall be limited from disclosure in ways or for reasons not authorized herein. 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 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 am not authorizing the release of mental health or psychotherapy records, alcohol or drug testing records or HIV test results.
I understand that my receipt of the services will be conditioned on whether I sign this document. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient in accordance with federal or state law.
In the event that there is a party identified above as Guardian, said person is acknowledging and confirming that they have legal authority to sign this document on behalf of the patient, and to consent to medical treatment on behalf of the patient. The Guardian agrees to indemnify, defend and hold harmless Mobile-Med Work Health Solutions, Inc., from any claims arising out of or relating to said consent on behalf of the patient.