Medical Release for COVID -19 Testing
College for Creative Studies
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Last 4 Digits of SSN
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Authorization to Share COVID Test Results* By signing this form, I authorize Beaumont Urgent Care to release Personal Health Information (PHI) related to my treatment for potential COVID-19 to my employer. The information you may release subject to this signed release form is as follows:
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Covid-19 Test Results and Work Status Report
Expiration of Authorization* The purpose of this release is to inform my employer of my test results and work status and to allow them to effectively maintain a safe work environment during this pandemic. This release will be valid for 1 year from the date submitted.
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Agree
Disagree
Right to Revoke Authorization* I understand that i have a right to revoke this authorization at any time. I understand if i revoke this authorization I must do so in writing and present my written revocation to the Medical Records Department of Beaumont Urgent Care by WellStreet at medicalrecords@wellstreet.com.
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Agree
Disagree
Signature
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Clear
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