Any pertinent health information will be shared with our School Nurse in case of an emergency.
HIPAA Privacy Authorization – Requested Only if Medical Information is Listed Above
I authorize the District School Board of Pasco County to disclose the protected health information listed on the attached Staff Emergency Contact Information form with emergency responders and/or health care providers providing services to me in emergency situations. This medical information may be used by these emergency responders and/or health care providers. This authorization shall be in effect until other written instructions and/or revocation is provided by me. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I understand that my employment, treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.