ECC COVID-19 Test Result Upload Form 2022-23

First Name

Last Name

If you are filling this out on behalf of a student or someone other than yourself, please enter their name. 

Choose which applies to you/your child

Please select... Red Orange Yellow Green Blue Purple Staff/Educator Specialist (all other service providers ie Music Teacher, Therapist or SEIT)

Upload test results:

I, the undersigned, hereby authorize disclosure of my Health Information by or at the direction of PAS as set forth below.

As used in this Authorization, “Health Information” means any and all information contained in my laboratory report(s) relating to COVID-19 testing, which may include but not be limited to information describing any or all of the following: my name, other identifying information, and information regarding COVID-19 infection, exposure, antibodies, or antigen testing (“COVID-19 testing”), and COVID-19 testing results.

Health Information may be disclosed by, or at the direction of, PAS pursuant to this Authorization for the limited purposes of: (1) safety protocols and other activities related to addressing COVID-19 in connection with my employment at PAS, my presence at PAS premises, and/or my use of PAS’ facilities. I also acknowledge that PAS may disclose, or direct disclosure, of my Health Information if required to do so by law and as otherwise permitted by law without my prior permission (such as public health reporting). This Authorization will remain effective for a period of three (3) years from the date of my signature below.

I understand that I have the right to revoke this Authorization, in writing, at any time (except to the extent that the PAS has acted in reliance upon this authorization) by sending written notification by secured carrier to: Park Avenue Synagogue, 50 East 87th Street, New York, NY 10128, Attn: Executive Director. I understand that a revocation will prevent PAS from further disclosure of Health Information pursuant to this Authorization, unless otherwise required by law to provide such information, but it will not retract the disclosures that have already been made pursuant to the Authorization.

I agree to the above statement

If you have any questions, please contact the ECC Office at (212) 369-2600, x150 or at ECCOffice@pasyn.org.