– if you do not have a registered address in Sweden

By signing this form, you consent to the Swedish eHealth Agency obtaining information about your

than seven (7) days after being vaccinated.

NB! Use this form only if you do not have a registered address in Sweden.

1.
coordination number or immunity number – a reserve number (temporary medical number)
cannot be used.
2. Send the completed form to
Covidbevis
Swedish eHealth Agency
Box 913
391 29 Kalmar
3.

Personal details (mandatory)

First name Middle name Surname
Yorgelis Andreina Diaz

Identity number (yyyymmdd-nnnn) Telephone number

199611892960 0790403950

Street address
Liljegatan 7b

Postcode City Country

24230 Hörby Sweden

Email address
PLEASE NOTE! If you have an address outside Sweden or a foreign
yordiaz97@gmail.com mobile phone number, you need to provide your email address.
Information about the posted letter will be sent to this email address.
Consent (mandatory)
Do you consent to having the Swedish eHealth Agency obtain information about
your vaccination?
I hereby request that the Public Health Agency of Sweden release information about my vaccina-
tions against COVID-19 from the national vaccination register to the Swedish eHealth Agency. This
means that I consent to the Public Health Agency of Sweden releasing the information needed to
-
ture below.
Signature Printed name
Yorgelis Diaz

1
In accordance with the EU General Data Protection Regulation (GDPR), this information is intend-
ed to provide an overview of how the Swedish eHealth Authority, as data controller, processes

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ID-19.

How do we process your personal data?

Our legal basis for the processing of personal data is that the processing is necessary for the per-

Employees who need to process the data in order to perform their duties may access your per-
sonal data.

2
What are your rights?
You have the right to obtain information about and access to the personal data that the Swedish
eHealth Agency processes about you, free of charge. You also have the right to receive a copy of
that information.

We will, at your request or on our own initiative, correct or delete data that is inaccurate or restrict
the processing of such data. You have the right to object to the processing of your data. You also
have the right, in certain cases, to receive your personal data in a machine-readable format or to
have the data transferred to a third party you designate, if technically feasible.

Authority for Privacy Protection (IMY)

(

processes your personal data, please contact the Swedish eHealth Agency at

telephone number
holidays) or by email at covidbevis@ehalsomyndigheten.se.

391 29 Kalmar

Information regarding secrecy

In addition to information on how the Swedish eHealth Agency processes your personal data, the

Council.

The Swedish eHealth Agency obtains information about your vaccination from the national vacci-
nation register of the Public Health Agency of Sweden. This is done so that the Agency can issue

-
ing this data from secrecy, thereby enabling the Swedish eHealth Agency to obtain data about

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lic Access to Information and Secrecy Act.