OSIIS - Authorization to Use or Share Protected Health Information to School or Day Care

I hereby authorize the Oklahoma Immunization Service to release my Immunization records and information located within the Oklahoma State Immunization Information System (“OSIIS”) to HOOKER PUBLIC SCHOOLS:

The information may be disclosed for the following purpose(s):

 

• To ensure the student meets Oklahoma eligibility requirements for schools/day cares as outlined in Title 70 O.S. § 1210.191 and Oklahoma Administrative Code ("OAC") 310:535-1-2 and OAC 310: 535-1-3

I understand that by voluntarily signing this authorization:

• I authorize the use or disclosure of my PHI as described above for the purpose(s) listed.
• I have the right to withdraw permission for the release of my information and revoke this authorization at any time in writing.
• I have the right to receive a copy of this authorization.
• I understand that unless the purpose of this authorization is to determine payment of a claim for benefits, signing this authorizationwill not affect my eligibility for benefits, treatment, enrollment, or payment of claims.
• I understand I may change this authorization at any time in writing. However, I understand I cannot restrict information that mayhave already been shared based on this authorization.
• Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and may no longer beprotected by HIPAA Privacy Regulations.

Unless revoked or otherwise indicated, this authorization’s automatic expiration date will be one year from the date of my signature or upon the occurence of the following event. [e.g. child no longer enrolled in school/day care center]

This form will be signed in person at enrollment.