I agree to the terms Read Terms Here
I, the undersigned, represent and warrant that I am the parent or legal guardian of the named person in this request and I have legal authority to act on behalf of this person or I am requesting documentation for myself and I am at least 18 years of age or am an emancipated minor.
I hereby authorize disclosure and/or release of the Proof of Immunization for the named person in this request to me in an electronic format. I understand this authorization is voluntary, and only applies to this one-time specific request for Proof of Immunization.
I hereby consent and specifically request to have one of the previously listed companies transmit to me by unencrypted email the Proof of Immunization for the above-named person in the request form. I understand that e-mail is not a confidential method of communication.
By providing my email address, I acknowledge and accept the risks of using unencrypted e-mail communications, which may include such risks as listed below:
I understand and agree that any of the above listed companies are not responsible for the security and confidentiality of email communications once sent to me. I release Health Hero of Georgia, Health Hero of Indiana, Health Hero of Pennsylvania, Health Heroes of Ohio, Health Heroes of Michigan, Health Hero USA LLC, WORKS!, and its subsidiaries, members, owners, directors, employees, attorneys, and agents from any liability or legal responsibility that may arise from this authorization and/or the release of the Proof of Immunization, whether the result of negligence, unauthorized access or any other cause. I acknowledge and agree that I am responsible for the privacy and security of my email communications and accounts.
I understand that I can receive a Proof of Immunization form via United States Post office delivery by making my request in writing. Your request must contain all the information that is required on the online electronic form and state that you have the legal authority to request medical information for the person named in your correspondence along with your signature, printed name and date. Mail your request along with a self-addressed and stamped envelope to:
Health Hero USA
7845 Colony Road, Suite C4 #262
Charlotte, NC 28226
I certify that the information provided on this form is true and accurate to the best of my knowledge, I have had sufficient opportunity to read this disclaimer, I have read and understood it, and I agree to be bound by its terms.
Due to HIPPA regulations medical information must be safeguarded. The information above must match what was provided on the Parent Consent form. If it does not we will not be able to complete your request. Proof of Immunization requests are sent to the email address provided on this from generally within 48 - 72 business hours. Please complete one request per student.