Release of COVID-19 Test Results to Employer
× First Care Clinics Patient Authorization for Employer: Release of COVID-19 Test Results
The employer information provided during my visit registration for today’s COVID-19-related test visit is for either my current or future employer who is requesting the test, and all information provided is true and complete.
I hereby give First Care Clinics permission to notify my employer of the results of today’s COVID-19 test, whether such results are positive or negative, via the contact information I have provided.
I understand that by signing this form I authorize First Care Clinics to provide my employer the results of today’s COVID-19 test and that not a full medical record resulting from today’s visit.
First Care Clinics will not release the full medical record of today’s visit to my employer unless I authorize by signing a separate release authorization.
First Care Clinics will not release any medical records related to prior or future visits unless I authorize by signing a separate release authorization.
I understand that by signing this form I authorize First Care Clinics to provide the results of today’s COVID-19 test to my current or future employer based on the information I have provided. This authorization is limited to my current or future employer.
I understand that if I want to provide other individuals or businesses the results of today’s COVID-19 test, I must furnish the information, on my own accord, directly to the individual or business or contact First Care Clinics’ for information on how to allow other individual or businesses access to my medical records.
I have been advised of my right to receive a copy of this authorization
PRIVACY CONTACT: If you have any questions about this policy or your rights, please contact our Privacy Officer via www.firstcareclinics.com .
CHANGES IN POLICY : This practice reserves the right to change its Privacy Policy based on the needs of the practice and changes in state and federal law and/or regulation.
IMPORTANT : Please read this document thoroughly before signing below.
I acknowledge that I have received and read this Authorization for Release of COVID-19 Test.