(SAMPLE) Consent for Use and Disclosure of Personal Health Information and Attestation

Consent for Use and Disclosure
of Personal Health Information and Attestation

As part of the provision of services, CareValidate and [EMPLOYER NAME] believe it’s important that you understand and agree that health information will be shared as part of** [EMPLOYER NAME]**’s COVID prevention and protection program. While this sharing of information is not subject to the Health Insurance Portability and Accountability Act (“HIPAA”), this Consent for Use of Personal Health Information and Attestation (the “Consent and Attestation”) is a consent for information to be disclosed for products and related services received from CareValidate, LLC and its affiliates (“CareValidate, LLC” or “we,” ”us,” ”our”).

1. Purpose

By signing below, you authorize CareValidate to disclose your personal health information for the purposes of confirmation and follow-up care regarding your COVID-19 test results or vaccination status to [EMPLOYER NAME] (“XXX”) and to prevent or lessen the serious and imminent threat that the coronavirus disease (COVID-19) presents to the health and safety of those with whom you may come into contact while at XXX facilities. You also agree that CareValidate may use and disclose your information as set forth in its Privacy Policy as set forth in the CareValidate Privacy Policy (the “Privacy Policy”).

2. Personal Health Information to Be Used or Disclosed.

You authorize the following personal health information about you to be used and disclosed as described in this Consent and Attestation:
Medical information that is collected from you or in connection with your receipt of products or your use of services, such as your medical history, vaccination status and/or test results.

We refer to this information altogether as your “Personal Health Information.”

3. Parties Authorized to Use and Disclose Your Personal Health Information.

In addition to the disclosure to XXX as set forth above, Personal Health Information may be collected, used, and disclosed by healthcare providers (including the medical providers who will review and order your tests) and CareValidate and its affiliates and vendors, such as the accredited laboratories that process any product you may purchase, the medical practitioners who evaluate your test results and answer any questions you may have, and our IT services providers (together, the “Authorized Parties”). Additionally, Personal Health Information may be shared as described in the Privacy Policy and as permitted or required by applicable law.

4. Purposes for Which Your Personal Health Information May Be Used or Disclosed.

Your Personal Health Information will be used and disclosed by XXX in order to monitor its COVID program, monitor compliance with its policies and other, legal purposes. Your Personal Health Information will be used and disclosed by the Authorized Parties for purposes related to providing you with products and services, to improve CareValidate’s products and services, for research, and for management and administration purposes. For example, your Personal Health Information may be used and disclosed for the following reasons:
To communicate with you and XXX regarding your test results and to provide you and XXX with other information related to the Products you purchase.
To enable the Authorized Parties to improve, develop, and evaluate products, services, materials, and programs related to the Products and Services.
To create aggregated data to help us develop new products and services or improve our current products and services, to offer new products and services to you, to perform quality control, and to perform data analysis.
Your Personal Health Information also may be aggregated and either de-identified or anonymized (altogether the “Anonymized Aggregated Data”) and used or disclosed by or to the Authorized Parties for research purposes. For example, we may use this Anonymized Aggregated Data to conduct research related to our products and services and to create a data repository to be used for future research related to developing new products and services, or for other future medical research. We also may receive remuneration from trusted third parties in exchange for access to the Anonymized Aggregated Data repository, e.g., for the trusted third-party’s medical research purposes, such as using the Anonymized Aggregated Data to help develop new drugs, tests, treatments, or cures.
Any other permissible reason identified in our Privacy Policy.
Once Personal Health Information has been disclosed or redisclosed in any of the ways described in this Consent and Attestation, federal and state laws may no longer protect such Personal Health Information.

5. Attestation.

You certify that any information you provide directly about your vaccination status is true, accurate, and complete.

6. Right to Refuse to Sign Consent and Attestation.

You are not required to sign this Consent and Attestation. The COVID-19 test is being provided for the purpose of disclosing the above information to XXX. If you do not sign the Consent, you will not be eligible to receive a test for COVID-19 through XXX’s testing program, though you may be able to purchase and receive a COVID-19 test outside of XXX’s testing program.

7. Right to Revoke Consent and Attestation.

You may revoke this Consent at any time. If you would like to revoke this Consent, you may deactivate your account, or contact us in writing at [email protected]. Please note, however, that any such revocation will not apply to Personal Health Information that already has been collected and disclosed under this Consent, including Anonymized Aggregated Data that has already been de-identified or anonymized. You may request a copy of your signed Consent and Attestation form by contacting us at [email protected].

8. Effective Date.

This Consent and Attestation shall be effective beginning on the date of your signature below. This Consent and Attestation does not expire. It will remain valid unless and until you revoke it.

9. Questions and Support.

If you have any questions related to this Consent and Attestation or our use of your Personal Health Information, please contact us at [email protected].

10. Signature

By clicking “I Accept” below:
You acknowledge that you have read and understand this Consent and Attestation.
You authorize the release of your Personal Health Information as described in this Consent and Attestation.
You acknowledge that you intend to be bound by and to sign this Consent and Attestation electronically.
[I ACCEPT BUTTON]
[TRACK DATE OF SIGNATURE / PROVIDE LINK TO COPY OF SIGNED AUTHORIZATION IN ACCOUNT OR BY EMAIL]