Fort Cobb

Please Fill Out The AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION Below

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION ("PHI")

Patient Name:

Date of Birth:

Social Security Number:

Medical Record Number:

I hereby authorize the Oklahoma State Department of Health ("OSDH") to release the following information to: Fort Cobb-Broxton School PO Box 130, 407 N 6th Street Fort Cobb, OK 73038. Information to be shared: Medical information relating to a positive confirmation or the novel coronavirus (SARS-CoV-2 or COVID-19) in the minor patient named above. The information may be disclosed for the following purpose(s) only: To notify the school that the minor patient attends in order for the school and OSDH to take measures that prevent the further spread of the coronavirus.

I understand that by voluntarily signing this authorization: I authorize the use or disclosure of the PHI as described above for the purpose(s) listed. I have the right to withdraw permission or the release my information. If I sign this authorization to use or disclose information. I can revoke this authorization at any time. The revocation must be made in writing to the person/organization disclosing the information and will not affect information that has already been used or disclosed.

I have the right to receive a copy of this authorization. I understand that unless the purpose of this authorization is to determine payment, a claim for benefits, signing this authorization will not affect the eligibility for benefits. treatment. enrollment or payment of clams. The medical information may indicate that the minor patient has the novel coronavirus (SARS •COV 2 or COVID-19), a communicable disease. I understand I may change this authorization at any time by writing to the person/organization disclosing the PHI. I understand I cannot restrict information that may have already been shared based on this authorization. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by the Privacy Regulation. Unless revoked or otherwise indicated, this authorization's automatic expiration date will be one year (from the date of my signature).

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FORT COBB BROXTON SCHOOLS

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION