Eden Health Medical, P.C. and Eden Health, Inc. (collectively, “Eden”) is providing to your employer (“Employer”) information obtained through a screening tool regarding Employer’s employees to help Employer monitor and reduce COVID-19 infections. Eden will disclose all information it learns via this screening tool to Employer to help address COVID-19. Eden will provide reporting on screening and monitoring activities to Employer as described herein.
1. The undersigned hereby authorizes Eden to use and/or disclose the protected health information described herein (“PHI”) about me, specific to COVID-19, to Employer under the conditions described below.
2. Only the following PHI will be used and/or disclosed:
a. Answers to (or opt out/lack of response to) daily or other periodic screening questions to assess the risk of exposure to COVID-19, including whether respondent has had a fever, experienced symptoms, had contact with an infected person, or travelled outside of the U.S.
b. Diagnosis of COVID-19 (if any);
c. Positive or negative result(s) of tests for COVID-19;
d. Result(s) of any antibody tests related to COVID-19; and
e. Employee’s fitness to work (whether fit, unfit, or fit subject to work modifications, if any) on-site in Employer’s offices in light of COVID-19 symptoms, risk assessment, or risk factors.
3. The PHI will only be used and/or disclosed for the following purposes:
a. For public health reasons, to monitor and reduce the spread of COVID-19 in the workplace.
b. To prevent threats to the safety of Employer’s employees or other individuals, relating to COVID-19.
c. To conduct medical surveillance of the workplace relating to COVID-19.
d. For Employer’s purposes, to assess and reduce health impacts and other harms relating to COVID- 19 and to promote workplace safety.
4. This authorization shall remain in effect for one year from the date I agree to it.
5. Eden is receiving direct or indirect remuneration to provide COVID-19 monitoring and screening services and disclose health information to Employer in order to promote workplace safety.
6. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form. Employer has advised that employees who do not complete the COVID-19 screening daily will not be permitted to work on site for workplace safety reasons. Please contact your HR representative with any questions.
7. I understand that I have the right to revoke this authorization at any time, by sending written notice to: email@example.com. However, I understand that I will not be able to revoke authorization in certain circumstances, such as (1) if Eden has already shared the information with Employer or (2) if disclosure is required to prevent a serious and imminent threat to a person’s health and safety. If I do not want to share my COVID-19 screening results with Employer, I understand that I should not use the Eden COVID-19 screening tool.
8. I understand that I have the right to refuse to sign this authorization.
9. I understand that PHI relating to COVID-19 used or disclosed pursuant to this authorization may be re- disclosed by the recipient and its confidentiality may no longer be protected by federal or state law.