AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby voluntarily authorize the disclosure of my protected health information, including any vaccination records, provided by Marco Drugs & Compounding pharmacy to:
Me via email, even though email is not a completely secure means of communication.
Me via SMS, even though SMS is not a completely secure means of communication.
The Florida Health Department and the Center for Disease Control and Prevention.
I also understand and agree to the following:
I may refuse to provide this authorization.
I may revoke this authorization at any time in writing.
I have a right to request and receive a copy of this authorization.
This authorization is effective immediately upon signing this form.