AUTHORIZATION FOR DISCLOSURE AND USE OF MEDICAL INFORMATION

FOR ADULT STUDENTS

Confidentiality of Medical Information Act (CMIA), Civil Code § 56, et seq.

Pursuant to California’s Confidentiality of Medical Information Act, I, authorize NRJY INC. D.B.A. COVID TESTING TODAY (“Vendor”), to disclose my medical information as described in this authorization to representatives from the school (“School”).  I also authorize the same representatives from the School to use the medical information for the purposes described in this authorization. 

This authorization is limited to the following types of information:   

COVID-19 test results, including but not limited to any results of tests administered at the School and sent to the Vendor, for processing to detect the presence of the COVID-19 virus (SARS-CoV-2).

The recipients may use the information for the following purpose:

Managing, controlling, and responding to COVID-19 infections among School personnel and students and medical accommodation requests.

Expiration Date:  The Vendor is no longer authorized to disclose medical information described in this authorization after December 31, 2022. 

Right to Receive Copy of This Authorization:  I understand that if I sign this authorization, I have the right to receive a copy of this authorization.  Upon request, the School will provide me with a copy of this authorization.

I authorize the disclosure and use of my medical information as described above for the purposes listed above.  I understand that this authorization is voluntary and that I am signing this authorization voluntarily.

FOR MINOR STUDENTS

Confidentiality of Medical Information Act (CMIA), Civil Code § 56, et seq.

Pursuant to California’s Confidentiality of Medical Information Act, I, the parent or legal guardian, authorize NRJY INC. D.B.A. COVID TESTING TODAY (“Vendor”), to disclose Student’s medical information as described in this authorization to representatives from the school (“School”), and to the Vendor’s employees and contractors.  I also authorize the same representatives from the School to use the medical information for the purposes described in this authorization. 

This authorization is limited to the following types of information:   

COVID-19 test results, including but not limited to any results of tests administered at the School and sent to the Vendor, for processing to detect the presence of the COVID-19 virus (SARS-CoV-2).

The recipients may use the information for the following purpose:

Managing, controlling, and responding to COVID-19 infections among School personnel and students and medical accommodation requests.

Expiration Date:  The Vendor is no longer authorized to disclose medical information described in this authorization after March 1, 2022. 

Right to Receive Copy of This Authorization:  I understand that if I agree to the present terms, and that I have the right to receive a copy of this authorization. 

I authorize the disclosure and use of Student’s medical information as described above for the purposes listed above.  I understand that this authorization is voluntary and that I am signing this authorization voluntarily.

FOR EMPLOYEES

Confidentiality of Medical Information Act (CMIA), Civil Code § 56, et seq.

Pursuant to California’s Confidentiality of Medical Information Act, I, authorize NRJY INC. D.B.A. COVID TESTING TODAY (“Vendor”), to disclose my medical information as described in this authorization to representatives, or from the school (“School”), or representatives from the company (including the Vendor) or organization.  I also authorize the same representatives to use the medical information for the purposes described in this authorization. This section also applies to COVID Testing Today’s employees and contractors.

This authorization is limited to the following types of information:   

COVID-19 test results, including but not limited to any results of tests administered and sent to the Vendor, for processing to detect the presence of the COVID-19 virus (SARS-CoV-2).

The recipients may use the information for the following purpose:

Managing, controlling, and responding to COVID-19 infections among School personnel and students and medical accommodation requests.

Expiration Date:  The Vendor is no longer authorized to disclose medical information described in this authorization after December 31st, 2022. 

Right to Receive Copy of This Authorization:  I understand that if I sign this authorization, I have the right to receive a copy of this authorization. 

I authorize the disclosure and use of my medical information as described above for the purposes listed above.  I understand that this authorization is voluntary and that I am agreeing to this authorization voluntarily.