Patient Authorization
I, the undersigned, have voluntarily provided a specimen for analytical testing. I authorize Babson Diagnostics, Inc. (“Babson”) to perform this laboratory test and to release the results of this testing to the prescriber who ordered the test and, when required by law, to public health authorities.
I understand the general risks and limitations of the laboratory testing. With all medical tests, there is a chance of a false positive or a false negative result. Other sources of error, while rare, include specimen mix-up, poor specimen quality or contamination, and technical errors in the laboratory. I understand that if testing results are inconclusive, I may be asked for an additional specimen. I understand that a nasal swab sample is to be collected, and I have been made aware of the possible risks associated with this, including but not limited to, runny nose, moderate discomfort, and minor bleeding from nose. If bleeding is severe or continues, seek medical treatment.
I understand the laboratory tests performed by Babson should not be used as a substitute for the provision of medical and health care services by a physician or other health care professional for diagnosing and treating a condition. I understand the importance of discussing the meaning, potential uses, risks and limitations of the test results with a physician or other health care professional, as Babson does not provide medical services, diagnosis, treatment or advice. I understand the following notices about the privacy and disclosure of my personal information:
- The test results will be retained in accordance with applicable federal and state laws.
- My personal information will be maintained in compliance applicable federal and state privacy laws.
- My personal information and test results may be disclosed if required by law, such as in response to a subpoena.
- I understand that if I share this information or these test results with anyone, I am responsible for any compromise ofconfidentiality that may result from such sharing.
I understand the following information regarding the storage and other uses of my specimen and information:
- Babson will retain my specimen only for the maximum duration permitted under applicable law or regulation, after whichpoint it will be properly destroyed in accordance with applicable laws and regulations and the testing laboratory’s standardoperating procedures. Until such time that my specimen is destroyed, Babson may de-identify my specimen and personalinformation to be used for regulatory compliance purposes; internal quality control; laboratory validation studies; or internalresearch and development.
I confirm that I am at least 18 years of age. I have read, or have had read to me, all the information in this document and understand what it says. I had the opportunity to ask any questions I may have about the laboratory testing and process, and all my questions have been answered to my satisfaction.