I authorize a nasopharyngeal swab for the COVID-19 test. I further understand, agree, certify, and authorize the following:
1) I am the patient, parent or legal guardian of the patient named below.
2) I authorize Express Care of Habersham, LLC to collect the specimen (nasopharyngeal swab)
3) I understand the test is for screening purposes only and if any treatment is needed, you should consult your health care provider.
4) The test will be performed in the clinic using the Cepheid Genexpert Xpress PCR platform authorized by the FDA under current EUA.
5) The cost of the test is $120 and tests for COVID, Influenza A&B, RSV
6) I understand that the cost of this test is NOT eligible for reimbursement by insurance, Medicare, or Medicaid as Express Care of Habersham, LLC DOES NOT participate in any insurance programs.
7) Express Care of Habersham will release the results of tests only to patient, parent or guardian of the person being tested. I understand that positive tests will be, by law, shared to the Georgia Department of Public Health for tracking purposes.
By completing and submitting the form, I acknowlege that I have read, understand, agree, certify and/or authorize the information above and further agree to hold Express Care of Habersham, LLC including agents, employees, and contractors from any and all liability and claims.