I, the undersigned, wish to provide evidence of my vaccination status to CTEH and BET Networks/ViacomCBS (Company), and I wish to have my immunization status considered, in the sole discretion of the Company and CTEH, as part of the audience casting process in connection with the production. I understand that I will be required to present my vaccination card as requested by the Company and CTEH, and my vaccination card may be copied for retention by the Company and CTEH. I certify that, to the best of my knowledge in the exercise of reasonable prudence and due diligence, the vaccination card that I have attached here is valid and current, and was created and presented to me in conjunction with my receipt of the COVID-19 vaccine. I consent to the Company’s and CTEH's search and viewing of any health or vaccination records maintained by the State or Federal health department or other government agency for the sole purpose of that the Company and CTEH may independently validating my vaccination status.
I expressly waive any and all rights that I would otherwise be entitled to pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), or other rules or laws regarding the dissemination of private medical information. I further agree to sign any additional authorizations that Company, CTEH or any medical, health, governmental or other parties shall deem necessary in connection with facilitating and effectuating my waiver of any and all of my rights pursuant to HIPAA.
I understand that the Company and CTEH will take steps to protect my identity and the confidentiality of my information, but that in the course of investigating or validating vaccination status, my identity may be inferred. I also understand that the Company and CTEH may disclose my personal information to public health authorities where required.
By checking the box below, you authorize the Company and CTEH to document and validate your vaccination status, as needed. You are entitled to a copy of this Consent. Any questions regarding this consent should be directed to your employer or designated representative.