Express Care of Habersham COVID-19 Antigen Patient Testing Consent 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 (nasal swab) and perform the SARS COV-2 antigen test with the Quidel SOFIA 2 or BD Veritor platform.
I understand the cost of the test $100 and is NOT ELIGIBLE FOR REIMBURSEMENT by insurance, Medicare or Medicaid. Express Care DOES NOT participate in any insurance plans, Medicare or Medicaid.
I understand that if testing is performed for, but not limited to, travel, job, or school that it is patient’s responsibility to assure that the antigen test is acceptable proof of no infection with SARS COV-2.
I understand if the result is NEGATIVE and patient is symptomatic and suspected to have COVID-19, a confirmatory PCR test may be needed to confirm.
I understand that the antigen test is authorized by the FDA by the Emergency Use Act (EUA). For more information you can visit https://www.quidel.com/sites/default/files/product/documents/FS20374101EN00.pdf
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.
I UNDERSTAND THIS TEST IS FOR PATIENT'S SCREENING PURPOSE ONLY. IT IS PATIENT'S RESPONSIBILITY TO FOLLOW UP WITH THEIR PRIMARY CARE PROVIDER SHOULD TREATMENT OR PAPER WORK FOR THEIR JOB IS NECESSARY.