• Paid and unpaid workers in hospital settings working directly with patients who are positive or at high risk for COVID-19. Such as but not limited to:
• Long-term care staff working directly with vulnerable residents. Includes:
• EMS providers who engage in 9-1-1 emergency services like pre-hospital care and transport
• Home health care workers, including hospice care, who directly interface with vulnerable and high-risk patients
• Residents of long-term care facilities
• Staff in outpatient care settings who interact with symptomatic patients. Such as but not limited to:
• Direct care staff in freestanding emergency medical care facilities and urgent care clinics
• Community pharmacy staff who may provide direct services to clients, including vaccination or testing for individuals who may have COVID
• Public health and emergency response staff directly involved in administration of COVID testing and vaccinations
• Last responders who provide mortuary or death services to decedents with COVID-19. Includes:
• School nurses who provide health care to students and teachers
This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment or healthcare operations and for the purposes permitted by law. Uses and Disclosures of Protected Health Information Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. We will also disclose your protected health to other physicians who may be treating you, or with other medical providers whom you have signed release of protected health information, or specific individuals you have identified in the “Exceptional Authorization” below
I authorize the release information including the diagnosis, records, examination rendered to me claims information. This information may be released to:
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:Required by law:
We may use or disclose your protected health information to the extent that is required by law. The use or disclosure will be made in compliance with law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, the disclosure may be made for the purpose of preventing or controlling disease, injury, or disability.
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
We can share health information about you with organ procurement organizations.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
We can use or share your information for health research.
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I hereby consent to evaluation, testing, and treatment as directed by my physician or his/her designee. I understand that EIXSYS Healthcare System serves as a teaching facility at times, and therefore, I may be attended to by students and residents affiliated with various educational programs.
I understand that this consent to treat will be valid for each visit I make to EIXSYS Healthcare System until revoked by me in writing.
I acknowledge that EIXSYS Healthcare System may release my protected health information as necessary for treatment and healthcare operations, and acknowledge that EIXSYS’s Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my diagnosis, health history, prognosis, treatment, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions, and laboratory test results, including HIV or the diagnosis of AIDS. I acknowledge and consent to allow EIXSYS Healthcare System to use health information exchange systems to electronically transmit, receive, and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information.Accidental Exposure to Health Care Worker:
I understand that Texas Law provides, and I give consent, that in the event a healthcare worker is exposed to my blood or body fluids, my blood may be tested for HIV and other communicable diseases, at no cost to me.Notice of Privacy Practice:
I acknowledge receipt of the “Notice of Privacy Practices” from EIXSYS Healthcare System.
ImmTrac2, the Texas immunization registry, has been designated as the disaster-related reporting and tracking system for immunizations, antivirals, and other medications administered to individuals in preparation for, or in response to, a disaster or public health emergency. From the time the event is declared over, ImmTrac2 will retain disaster-related information received from health-care providers for a period of 5 years. At the end of the 5 year retention period, client-specific disaster-related information will be removed from the Registry unless consent is granted to retain the client information in ImmTrac2 beyond the 5 year retention period. The Texas Department of State Health Services (DSHS) encourages your voluntary participation in the Texas immunization registry. Consent for Retention of Disaster-Related Information and Release of Information to Authorized Entities I understand that, by granting the consent below, I am authorizing retention of my (or my child’s) disaster-related information by DSHS beyond the 5 year retention period. I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, my (or my child’s) disaster-related information may by law be accessed by: • a state agency, for the purpose of aiding and coordinating communicable disease prevention and control efforts, and / or • a physician or other health-care provider legally authorized to administer immunizations, antivirals, and other medications, for treating the client as a patient; I understand that I may withdraw this consent to retain information in the ImmTrac2 Registry beyond the 5 year retention period and my consent to release information from the Registry, at any time by written communication to the Texas Department of State Health Services, ImmTrac2 Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347. By my signature below, I GRANT consent to retain my disaster-related information (or my child’s information if younger than age 18) in the Texas immunization registry beyond the 5 year retention period.
By signing this form electronically, and clicking on "Submit Signature", you are agreeing to the terms stated herein. Privacy Notification: With few exceptions, you have the right to request and be informed about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004) Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com • ImmTrac2 DC Texas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347 PROVIDERS REGISTERED WITH ImmTrac2 Please enter client information in ImmTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client’s record. Stock No. F11-12956 Revised 03/2017
|Apartment # / Building #||
|Mother's First Name||
|Mother’s Maiden Name||
|American Indian or Alaskan Native|
|Black or African American|
|Native Hawaiian or Other Pacific Islander|
Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com • ImmTrac DC Texas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347
Please enter client information in ImmTrac2 and affirm that consent has been granted.
DO NOT fax to ImmTrac2. Retain this form in your client’s record.