Eden Health Medical, P.C. and Eden Health, Inc. (collectively, “Eden”) is providing to your employer (“Employer”) information obtained through a vaccination status tracking tool regarding Employer’s employees and information regarding individuals’ COVID-19 vaccination eligibility and status to help Employer monitor and reduce COVID-19 infections. Eden will disclose all information it learns via this tracking tool to Employer to help address COVID-19. Eden will provide reporting on vaccination activities to Employer as described herein.
1. By signing below, I hereby authorize 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. Eligibility to receive a COVID-19 vaccination; and
b. 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:
a. For public health reasons, to monitor and reduce the spread of COVID-19 in the workplace.
b. To prevent threats to the health and safety of Employer’s employees and contractors 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 vaccination information collection services and disclose health information to Employer 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. Employer may have policies pertaining to employees’ vaccination status and ability to work onsite. 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 vaccination information with Employer, I understand that I should not use the Eden COVID-19 vaccination tracking 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.
[EMPLOYEE NAME] ______________________________