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Authorization to Disclose Health Information

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Color Health, Inc. (“Color”) is providing certain Covid-19 Services at the request of the institution that is paying for or otherwise making the Covid-19 Services available to you (e.g., the employer, school, or entity for which you perform or will perform services, or will enter their facilities) (the “C19 Program Sponsor”) to help guide the C19 Program Sponsor’s determination about the safety of admitting individuals to their facility/facilities during the Covid-19 pandemic, and to facilitate (directly or through a C19 Program Sponsor contractor/vendor) aspects of the Covid-19 Services program (each, an “Authorized Use”). Covid-19 Services may include Covid-19 testing and vaccination, as well as a platform that collects self-reported information concerning Covid-19 testing results and Covid-19 vaccination status. In connection with the Covid-19 Services, you will share certain personal and health information (“Protected Health Information” or “PHI”) with Color. For purposes of this authorization, your PHI includes the information that Color generates about you in performing the Covid-19 Services, for example, your Covid-19 test results, and/or self-reported health information including but not limited to your Covid-19 vaccination status and Covid-19 rapid test results.

Purpose of this Authorization

To facilitate and execute the Covid-19 Services, and as required or permitted by applicable law, rule, or order, by signing this authorization form, you authorize Color to share your PHI with the C19 Program Sponsor, including its contractors and vendors, in connection with an Authorized Use, each time the Covid-19 Services are performed.

Expiration of Authorization

This authorization will expire after five (5) years from the date of your authorization.

Your Rights:

By signing this authorization form, you understand and acknowledge the following:

  • I understand that I am not required to sign this authorization form, but that my refusal will make me ineligible to receive the Covid-19 Services through the C19 Program Sponsor’s program.
  • I may revoke my authorization at any time, but to do so, I must request my revocation by filling out the form on My revocation will take effect upon Color’s receipt, except to the extent that Color has taken action in reliance upon this authorization prior to my revocation.
  • I have received a copy, or have the right to receive a copy, of this authorization or to inspect the information contained therein by contacting
  • I understand that Color is receiving payment from the C19 Program Sponsor or its affiliate in connection with the Covid-19 Services.
  • I understand that this authorization shall apply for each instance that Color performs the Covid-19 Services for me, including, but not limited to, sharing my PHI with the C19 Program Sponsor each time I take a Covid-19 test if I repeat testing through the C19 Program Sponsor’s program.
  • I understand that the information disclosed pursuant to this authorization may no longer be protected by federal or state medical confidentiality laws if the recipient of my PHI is not subject to such laws and may be re-disclosed by the recipient.