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 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 screening tool and COVID-19 vaccination services to Employer to help address COVID-19. Eden will provide reporting on screening, monitoring, and vaccination 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. Whether a COVID-19 vaccination was administered (including whether the dose administered was a first or second dose, and the date of vaccination, if applicable); 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 you agree to it.
5. Eden is receiving direct or indirect remuneration to provide COVID-19 monitoring, screening, and vaccination 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 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. Additionally, Employer may have policies pertaining to employees’ vaccination status. Please contact your HR representative with any questions.
7. You have the right to revoke this authorization at any time, by sending written notice to: firstname.lastname@example.org. If you revoke your authorization, this will prevent further uses and disclosures of your information, except 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 you do not want to share your screening and vaccination information with Employer, you should not use the Eden COVID-19 screening tool or vaccination services.
8. You have the right to refuse to sign this authorization.
9. 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.