Employee Consent

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION IN COMPLIANCE WITH ALL CORE ELEMENTS AND REQUIRED STATEMENTS PURSUANT TO 45 CFR §164.508

I hereby authorize and request that HealthTrackRx furnish to {employer_name} and its authorized representative, the results of my COVID-19, antigen or PCR, test.

This release of the aforementioned records is to assist and facilitate {employer_name} with COVID-19 testing for all its employees and/or contractors.

A photocopy or facsimile of this authorization is considered as effective as the original and will be effective until termination of my employment with {employer_name} or revoked, in writing, by me. I understand I have the right to revoke this authorization at any time, provided the revocation is in writing, and sent to HealthTrackRx at 1500 Interstate 35W, Denton, Texas 76207.  Revocation of this Authorization will not affect information released prior to the notification of cancellation.

I understand that authorizing the disclosure of this health information is voluntary.  I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.  I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by Federal confidentiality rules.

I understand that my refusal to sign this form does not affect my health care treatment or the payment of my health care treatment. Medical providers may not condition treatment or payment on execution of this authorization.