AUTHORIZATION and RELEASE:

I have read, or have had read to me, the current Vaccine Information Statement as well as the additional information regarding protected health information. I have had a chance to ask questions. I understand the benefits and risks of an influenza vaccination and request that the vaccine be given to me. By my signature below, I hereby authorize VaxPro to release proof of influenza vaccination to myself at the address provided above, my employer and the Wisconsin Immunization Registry (WIR). I also understand that the information used and/or released as a result of this authorization may no longer be protected by federal privacy laws and may be further used and/or released by persons or organizations receiving it without obtaining my authorization. I agree to release and hold harmless VaxPro (and its employees and agents), my employer/institution (and its affiliates, employees and agents), against any and all liability for adverse reactions, illness, or injuries directly or indirectly resulting from the vaccination. I acknowledge that VaxPro has posted a copy of its Notice of Privacy Practices for my review and I understand these practices. If I have questions or concerns, I can contact VaxPro ( info@vaxpro.com) .
EXPIRATION DATE: This authorization will expire upon VaxPro’s delivery of proof of my influenza vaccination to my employer, if my employer requires such proof.

ADDITIONAL INFORMATION REGARDING THE RELEASE OF PROTECTED HEALTH INFORMATION (PHI)

VaxPro recognizes the patient’s right to confidentiality of protected health information in accordance with the federal privacy rule and state law. Patients should be aware of the following information when requesting the release of protected health information:

Right to Refuse to Sign this Authorization. A patient has the right to refuse to sign this authorization form. However, VaxPro will not provide the influenza vaccine to the patient even if his or her employer requires proof of vaccination for purposes of meeting the employer’s policy and/or patient’s employment duties.
Right to Receive a Copy of this Authorization. A patient has the right to request a copy of the signed authorization.
Right to Revoke Authorization. A patient has the right to revoke an authorization at any time by following the instructions provided in VaxPro’s Notice of Privacy Practices. Revocation of this authorization will not apply to information that has been released in compliance with this authorization prior to the receipt of the written notice of revocation.
Re-disclosure of Information by Recipient. Any disclosure of protected health information carries with it the potential for an unauthorized redisclosure. If the person(s) and/or organizations to whom my protected health information is disclosed are not health care providers, health plans or health care clearinghouses subject to the federal privacy rule, the protected health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and may be redisclosed without obtaining my authorization.

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