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COVID-19 Release Form.pdf

UM-HIPAA-Release_Informed-Consent.pdf
Preview of COVID-19 Release Form
🔗 Source: coronavirus.olemiss.edu
📊 Size: 348 KB
📄 Pages: 1 page
⬇️ Downloads: 139

Summary

I authorize Dr. Scott Miscovich and Premier Medical Group USA to disclose COVID-19 testing records to the University of Mississippi, including personal information, for the purpose of notifying the university of COVID-19 status in campus communities. I understand that this authorization allows for the release of protected health information under HIPAA and that I may revoke it in writing at any time, except to the extent that action has been taken in reliance on it, and it expires automatically one year from the signature date. I also authorize Premier Medical Group to conduct COVID-19 testing through a nasal PCR swab or blood draw and disclose test results to governmental entities as required by law, acknowledging the potential for false positive or false negative results and assuming responsibility to seek medical advice and treatment from my medical provider if necessary.

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Description

I authorize Dr.

Technical Information

  • File Format: PDF
  • File Size: 348 KB
  • Pages: 1
  • Language: EN
  • Total Downloads: 139
  • Last Updated: 1 week ago

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