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Employees Managers Exemptions - Medical Exemptions - Religious Travel/Contingent Exemptions Request ID External Vaccination Submissions Travel/Contingent External Vaccination Submissions Immunization Consents & Authorizations EH Vaccine Revoke Consent Contingent Worker Black Diamond Status Templates Student Immunization Consents & Authorizations
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Immunization Consents & Authorizations

Add Immunization Consent & Authorization

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Section 1
CONSENT FOR GEISINGER EMPLOYEE HEALTH TO USE AND DISCLOSE IMMUNIZATION INFORMATION
1. I agree that if I receive the Seasonal Influenza Vaccine Immunization from a Geisinger Employee Health sponsored flu shot event, and if I am a Geisinger provider entity patient, my information regarding the Seasonal Influenza Vaccine Immunization will be uploaded to my Geisinger medical record, and, accordingly, may be accessed by the following Geisinger provider entities (as defined below), which may access my Geisinger medical record in connection with providing me with medical care: Geisinger Clinic (all sites), Geisinger Medical Center (all campuses), Geisinger Wyoming Valley Medical Center (all campuses), Geisinger Community Medical Center (all campuses), Geisinger Lewistown Hospital, Geisinger Bloomsburg Hospital, Geisinger Jersey Shore Hospital, Geisinger Pharmacy, LLC, Family Health Associates of Geisinger-Lewistown Hospital, and any after acquired Geisinger provider entities (but excluding Marworth and Geisinger Community Health Service), and any other non-Geisinger entity which uses or may in the future permissibly use my Geisinger medical record (collectively referred to as “Geisinger provider entities”).
2. I agree that if I receive any other immunizations from a Geisinger Employee Health sponsored event, and if I am a Geisinger provider entity patient, my information regarding any such immunizations will be uploaded to my Geisinger medical record and may be accessed by Geisinger provider entities (as set forth above) in connection with providing me with medical care and for any other purpose set forth in the applicable Notice of Privacy Practices.
3. I further agree that Geisinger Employee Health may disclose my information regarding Seasonal Influenza Vaccine Immunization and other immunizations, all as applicable, (i) to Geisinger entity administrative personnel for uses related to my employment, (ii) to Geisinger Health Plan for statistical purposes, and (iii) for any other required reporting by Geisinger Employee Health. Notwithstanding the foregoing, Geisinger Employee Health will not specifically disclose or otherwise share with my supervisor or any other individual who directly makes decisions regarding my employment (collectively, “Supervisor”) whether or not I have received the Seasonal Influenza Vaccine Immunization and other immunizations, as applicable; rather, Geisinger Employee Health will share with my Supervisor only whether I am in compliance with Geisinger policy requirements regarding the Seasonal Influenza Vaccine Immunization and any other immunizations, as applicable.
4. This Consent shall supersede and replace any and all other consents, whether written or oral, regarding the subject matter hereof. By signing below, I understand, agree, and certify that I have read this Consent, I understand what it says, and I agree with its terms. I have had the opportunity to review and ask questions regarding this Consent.
This electronic submission represents my signature, and it is legally binding. I understand that making a false statement may lead to disciplinary action up to and including termination of employment, at the sole discretion of Geisinger. I understand what this Disclosure and Consent says, and if I had any questions, they have been answered.
 *
 
Section 2
AUTHORIZATION FOR GEISINGER PROVIDER ENTITIES TO RELEASE IMMUNIZATION INFORMATION TO GEISINGER EMPLOYEE HEALTH
1. If I am a Geisinger provider entity patient, I agree that Geisinger Employee Health may query my Geisinger medical record for information regarding the Seasonal Influenza Vaccine Immunization or any other immunization that appears within my Geisinger medical record (i) for uses related to my employment, (ii) for statistical purposes of Geisinger Health Plan, and (iii) for required reporting purposes, all in accordance with Geisinger Employee Health policy. I agree that the applicable Geisinger provider entity may facilitate such query of my Geisinger medical record by Geisinger Employee Health.
2. I understand that signing or not signing this Authorization will not in any way affect treatment I receive from any Geisinger provider entity. No Geisinger provider entity can require me to sign this Authorization to receive treatment. This Authorization shall remain in effect until the termination of my employment relationship with Geisinger or until I revoke it. I may revoke this Authorization at any time by contacting Geisinger Employee Health at 570-214-9424 and asking how to revoke this Authorization in accordance with the applicable Notice of Privacy Practices.
3. This Authorization shall supersede and replace any and all other authorizations, whether written or oral, regarding the subject matter hereof. By signing below, I understand, agree, and certify that I have read this Authorization, I understand what it says, and I agree with its terms. I have had the opportunity to review and ask questions regarding this Authorization.
This electronic submission represents my signature and it is legally binding. I understand that making a false statement may lead to disciplinary action up to and including termination of employment, at the sole discretion of Geisinger. I understand what this Disclosure and Consent says, and if I had any questions, they have been answered
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