Authorization for the Use or Disclosure of Health Information from Kaiser Permanente

Signing this HIPAA Authorization (“Authorization”) allows us* to the use and disclose the fact of your COVID 19 vaccination for purposes of administering KP COVID 19 Sweepstakes reward.

I understand that Kaiser Permanente* is required to maintain and safeguard the privacy and security of my information under applicable federal, state and local health information privacy rules that govern the use and disclosure of my information, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended from time to time.

By agreeing to this Authorization, I authorize Kaiser Permanente to use and disclose within and among the Kaiser Permanente Entities (see below), such as my regional health plan and regional Permanente Medical Group, and other designated entities that collaborated in vaccine administration, including but not limited to the sweepstakes administrator, the fact of my COVID 19 vaccination, the contact information that I have provided to kp.org (my name, mailing and email addresses, and telephone number, which is protected health information (PHI) under HIPAA and applicable state law, so that Kaiser Permanente may use and disclose my information to deliver rewards under for the COVID 19 Vaccination Sweepstakes that Kaiser Permanente is offering. As required by applicable law, this Authorization lasts for one (1) year from the date of your signature (December 31, 2022 for California residents) unless I revoke it.

I understand that I have the right to revoke this Authorization, in writing, at any time. Instructions for revocation can be found by visiting the kp.org page provided in the submission confirmation email that will be sent upon submission of this authorization with subject line “Next steps for Kaiser Permanente ImmUNITY Sweepstakes.” If I revoke my HIPAA authorization agreement, I will be ineligible to receive the reward. Kaiser Permanente will stop using or disclosing my information for these purposes upon Kaiser Permanente’s receipt of my revocation. However, my revocation will not be effective with respect to actions Kaiser Permanente took in reliance of my Authorization.

I understand that once information is used or disclosed under this Authorization, there is a potential for it to be redisclosed and may no longer be protected under federal or state privacy law. However, state law may prohibit the person receiving my information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law.

I understand that I have a right to receive a copy of this Authorization by visiting the kp.org page provided in the submission confirmation email that will be sent upon submission of this authorization with subject line “Next steps for Kaiser Permanente ImmUNITY Sweepstakes.“

Kaiser Permanente will not condition my treatment, payment, or eligibility for benefits on whether I agree to this Authorization electronically or on paper. I have read the above information and authorize the use and disclosure of my information by Kaiser Permanente for the purposes described herein.

By clicking and typing your name below, you acknowledge that you have read and agree to the terms of this Authorization.

If you are the parent or personal representative of the Individual(e.g., a minor under age 18), by clicking and typing the names indicated below, you acknowledge on behalf of the Individual that you have read and agree to the terms of this Authorization.