Employee COVID-19 Vaccine Verification Release Form

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO EMPLOYER

This authorization, if signed, will authorize Pikeville Medical Center, in its capacity as a covered entity, to use and disclose certain protected health information (“PHI”) about the patient named below.  Pikeville Medical Center, in its capacity as a covered entity, shall hereinafter be referred to as “PMC.”  Pikeville Medical Center, in its capacity as an employer of the patient named below, shall hereinafter be referred to as “Employer.”  This authorization is voluntary and you may refuse to sign this authorization.

1. I hereby authorize disclosure of PHI relating to:

Fields marked with an asterisk* are required

2. The purpose of the disclosure is: Provide proof of COVID-19 vaccination(s) to Employer

3. The PHI to be disclosed is: Proof of COVID-19 vaccination(s)

4. PMC is authorized to disclose this information to Employer.

5. I acknowledge the following statements:

*          I understand that I may revoke this authorization at any time by notifying PMC in writing of my intent to revoke this authorization.  If I notify PMC in writing of my intent to revoke this authorization, such revocation will not have any effect on actions taken by PMC in reliance upon the authorization prior to receiving such notification.  Notification of revocation must be addressed to: Attention: Privacy Officer, Pikeville Medical Center, 911 Bypass Road, Pikeville, KY 41501

*          I understand that PMC may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.

*          Unless otherwise revoked, I understand that this authorization will expire 180 days from the date of signature.

*          I understand that there is potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer protected by federal law.

*          PMC will provide me with a copy of this authorization form after I sign it.

*          If anyone other than the patient whose information is being requested signs this authorization, proof of his/her relationship to the patient and his/her authority to act on behalf of the patient must be provided, such as a copy of durable power of attorney or an Order Appointing Executor/Executrix.

Signature of Patient*:

If not signed by the patient, Patient’s Legal Representative:

Relationship: