Express Care of Habersham COVID-19 PCR Patient Testing Consent Form
By completion and submission of this form, I authorize a nasopharyngeal swab for COVID-19 Test as ordered by my authorized healthcare provider. I further understand, agree, certify, and authorize the following:
I am the patient, parent or legal guardian (if the patient is a minor or dependent) of the patient named below.
I authorize Express Care of Habersham, LLC to collect the specimen (nasopharyngeal swab).
The Express Care of Habersham, LLC has contracted with Genetworx Laboratories for laboratory analysis and report of my, my child’s, or dependent’s specimen. I authorize Genetworx Laboratories to perform testing on my specimen.
I understand that the billing of any insurance or the patient will be performed by the laboratory performing the testing. The $40 testing fee is NOT eliqible for reimbursement by insurance, Medicare or Medicaid as Express Care of Habersham does not participate in any insurance programs.
I understand that processing of the specimen and results may take between 4 to 5 days, but may take longer depending upon the lab processing. We have NO CONTROL over speed at which specimens processed.
Express Care of Habersham will release the results of my test only to the patient, parent or legal guardian of the person being tested. I understand that positive results will be, by law, shared with the Georgia Department of Public Health and Centers for Disease Control for tracking purposes.