Eden Health Medical, P.C. and Eden Health, Inc. (collectively, “Eden”) is providing to Sentry Centers Holdings LLC, d/b/a/ Convene (“Convene”) information regarding individuals’ COVID-19 vaccination eligibility and status to help Convene reduce COVID-19 infections in its workplaces. Eden will disclose all information it learns via this screening tool to Convene to help address COVID-19. Eden will provide reporting on vaccination activities to Convene 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 Convene under the conditions described below.
2. Only the following PHI will be used and/or disclosed:
1. Eligibility to receive a COVID-19 vaccination; and
2. Whether a COVID-19 vaccination was administered (including whether the dose administered was a first or second dose).
3. The PHI will only be used and/or disclosed for the following purposes:
1. For public health reasons, to reduce the spread of COVID-19 in the workplace.
2. To prevent threats to the safety of Convene’s workplace members or other individuals, relating to COVID-19.
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 vaccination tracking services and disclose health information to Convene in order to promote workplace safety.
6. Your treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether you sign this form. Convene has advised that members who do not provide proof of vaccination will not be permitted to attend Convene workplaces for safety reasons. Please contact Convene or 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: firstname.lastname@example.org. 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 Convene 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 vaccination results with Convene, I understand that I should not use the Eden COVID-19 vaccination status 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.