All information is kept strictly confidential and is only shared as required by law.
HIPAA Authorization and Waiver of Liability
The undersigned has requested a COVID-19 and/or other respiratory pathogen diagnostic test for the undersigned and/or the minor child of the undersigned at the drive-through Baltimore Community testing location located in the parking lot of 122 Slade Ave. Baltimore, Maryland 21208, 3300 Old Ct. Rd. Baltimore, MD 21208 or other location (the "Baltimore Community COVID-19 Testing"
The undersigned hereby releases from any liability all of the individuals performing the testing swabs, the STAR-K Kosher Certification, Inc., and any other entity involved in hosting the Baltimore Community COVID-19 Testing, and all of their respective officers, directors, employees and agents.
The undersigned authorizes ACCU REFERENCE MEDICAL LABS, Timonium Urgent Care Center, Dr. Yosef Levenbrown, Dr. Julian Jakobovits and any other healthcare provider I designate as a recipient of the protected health information referenced herein to use and disclose the protected health information described below to Jewish day schools in the Greater Baltimore area and/or my place of employment as they deem appropriate.
Effective Period: This authorization for release of information covers the period of healthcare from 8/1/2020 TO 12/31/2022.
Extent of Authorization: The undersigned authorizes the release of his/her complete health record.
This medical information may be used by the person the undersigned authorizes to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as the undersigned may direct.
The undersigned understands that the undersigned has the right to revoke this authorization, in writing, at any time. The undersigned understands that a revocation is not effective to the extent that any person or entity has already acted in reliance on this authorization or if the undersigned's authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
The undersigned understands that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
You have selected to have a rapid test. You will be emailed forms to print and bring with you to the test site. After submitting this form, you will be directed to a link where you need to finish registration with Timonium Urgent Care. This is required in order to bill insurance. If you are choosing to pay for the rapid, you can ignore this. Just print the documents from the confirmation email that you will recieve.
NOTE: The link will display an appointment time and location at Timonium Urgent Care. IGNORE that, it is just part of their system. Testing is at STAR-K and Beth Tfiloh as posted on www.baltimorejewishlife.com here.