CONFIDENTIALITY OF MEDICAL INFORMATION ACT (CMIA), CIVIL CODE § 56, ET SEQ.
Pursuant to California’s Confidentiality of Medical Information Act, I and Parent/Guardian authorize Inspire Diagnostics to disclose my medical information described in this authorization to St. Johns Soccer Club. I and Parent/Guardian also authorize the same representatives from the St. Johns Soccer Club 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). The recipients will use the information limited to accessing the COVID-19 test results.
Right to Receive Copy of This Authorization: I and Parent/Guardian understand that if I consent to this authorization, I and Parent/Guardian have the right to receive a copy of this authorization. Upon request, the St. Johns Soccer Club will provide me with a copy of this authorization.
I and Parent/Guardian authorize this test and the disclosure and use of my medical information as described above for the purposes listed above. I and Parent/Guardian understand that this authorization is voluntary and by clicking the CONSENT button below, I and Parent/Guardian hereby consent to the terms of this authorization voluntarily.