CONFIDENTIALITY OF MEDICAL INFORMATION ACT (CMIA), CIVIL CODE § 56, ET SEQ.
Pursuant to California’s Confidentiality of Medical Information Act, I authorize Inspire Diagnostics to disclose my medical information described in this authorization to the school district's Covid Designee/s and Solano Community College. I also authorize the same representatives from the school district and Solano Community College to use the medical information for the purposes described in this authorization.
This authorization is limited to the following types of information and recipients may use the information for the following purpose (s) :
This authorization is specifically for the COVID-19 testing/test results administered to detect the presence of the COVID-19 virus (SARS-CoV-2) and/or Combo testing/tests administered to detect the presence of COVID-19 and influenza A/B viruses. The recipients will use the information limited to accessing the COVID-19 and/or COVID-19 and influenza A/B test results.
This authorization is also used for billing purposes, which Inspire Diagnostics reserves the right to bill the insurance company for reimbursement. If no/incomplete insurance information is provided, Inspire will perform an Insurance Discovery for accurate information which is needed to submit a claim to the insurance company.
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, Inspire Diagnostics will provide me with a copy of this authorization.
I authorize this test and the disclosure and use of my medical information as described above for the purposes listed above. I understand that this authorization is voluntary and by clicking the CONSENT button below, I hereby consent to the terms of this authorization voluntarily.