PAGING DR. NEIL / PANCHALMED, PC
COVID-19 PATIENT TESTING SERVICES AGREEMENT

This COVID-19 Patient Testing Services Agreement (“Agreement”) specifies the terms and conditions under which Interport Maintenance Co., Inc. or its affiliate(s) ("Employer") may offer to its employees (each, a “Patient” and collectively, the "Patients") certain healthcare services of PanchalMED PC, a New Jersey professional corporation d/b/a Paging Dr. Neil (“Provider”), which are summarized as follows: (1) COVID-19 nasopharyngeal tests without diagnostic examination and (2) patient access to the Provider’s health data communication plan (collectively, the “Services”). 

SUBSCRIPTION PRACTICE EXPLAINED

Services are made available to Patients in exchange for the payment of fees by Employer to Provider as outlined in Schedule A (the “Fees”). Services by Provider will occur at Employer’s facility located at 635 Delancy Street, Newark, New Jersey 07105 (“Employer’s Facility”) on a regular basis as scheduled by the mutual agreement of the parties until such time as Employer advises Provider in writing that Services are no longer needed. Services shall not be billed to Patient, but rather will be paid for by Employer. 

SERVICES AND BENEFITS 

Provider will provide Services to Patients in exchange for the Fees paid by Employer. Provider may only update Schedule A with the mutual written agreement of Employer. 

 

SERVICE AND LABORATORY TESTING FEES 

For making Services available to Patients, Employer will pay the Fees at the time Services are provided.  Fees are specified in Schedule A.  In addition to the Fees, Employer agrees to pay any resulting credit card and additional transaction processing fees related to payment of the Fees. 

The Fees do not include payment for laboratory testing fees, which may be covered by Patient's private health insurance, Medicare or Medicaid, or government assisted program. Any laboratory testing fees and corresponding co-payments or deductibles will be collected by the laboratory facility from the Patient or his/her applicable health insurance plan.

PAYMENT OPTIONS

If a Patient elects to obtain Services from Provider, Provider shall submit the invoice to Employer and shall not require the Patient to pay. Provider acknowledges that any patient agreement or consent it may require a Patient to sign shall not include a requirement that Patient pay for the Services. Employer will pay Fees by debit or credit card, or ACH authorization.    

 

APPOINTMENTS AND SCHEDULING

Services with Provider are scheduled by email or written agreement between the parties and otherwise documented through Provider’s Health Data Communication Plan.  Services will be delivered at Employer’s Facility.  

COMPLIANCE WITH LAW AND JURISDICTION

Provider agrees to make Services available for the Fees in compliance with all local, State, and Federal laws.  This Agreement shall be governed by and construed in accordance with the laws of the State of New Jersey.  If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement or the activities of either Provider or Patient under this Agreement, or any change in judicial or administrative interpretation of any such law, regulation or rule, this Agreement shall be deemed modified so as to remain in compliance with such laws. Any disagreement over the terms of this Agreement shall be brought in a court of competent jurisdiction in the State of New Jersey. 

PROVIDER IS NOT AN INSURER

Provider is not an insurance company and is not promising or delivering unlimited care or services for the Fees.

SCHEDULE “A”

Services & Fees

Services to be provided include (1) COVID-19 nasopharyngeal test without diagnostic examination and associated laboratory testing fees, and (2) patient access to the Provider’s Health Data Communication Plan (the “Services”). The below Fees shall apply for Provider’s provision of Services.  These Fees will be the responsibility of Employer.

1.  COVID-19 Nasopharyngeal Test

The COVID-19 nasopharyngeal test without diagnostic examination shall include Provider traveling to Employer’s Facility, performance of a COVID-19 nasopharyngeal swab, and the forwarding of the swab to a laboratory for COVID-19 testing. Provider shall notify Patient of the results of Patient’s COVID-19 through Provider’s Health Data Communication Plan. 

2.  Health Data Communication Plan Service

Provider will provide access for Patient to Provider’s health data communication plan (“Health Data Communication Plan”). The Health Data Communication Plan will permit Patient to correspond with Provider electronically regarding Provider’s Services to Patient. The Health Data Communication Plan will facilitate Patient/Practice Services-related communication in efforts to also provide patient with guidance, education, and support regarding Services provided to Patient, as well as providing a platform to facilitate ongoing electronic communication exchanges between Provider and Patient. Patient can electronically store his or her medical information on Provider’s Health Data Communication Plan. Thereafter, Provider can retrieve Patient’s electronically stored medical information for use in the provision of Provider’s Services to Patient. 

If Patient has an urgent question or concern related to the Services, Patient shall contact the Provider. However, in an emergency, Patient should call 9-1-1 and/or utilize emergency medical services.

ELECTRONIC PRACTICE COMMUNICATIONS

Provider prohibits transmission of electronic communication from Patient, except through Provider’s Health Data Communication Plan. Electronic communications by Patient to Provider not through Provider’s Health Data Communication Plan are not secure and do not ensure protection of Patient’s Protected Health Information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  In the event the communication is time-sensitive, Patient must communicate with Provider by telephone or in-person.  Provider refers Patient to Provider’s Electronic Communications Agreement, which is integrated herein by reference.

3.  Service Fees

The Fees shall be $100.00 per test, with the understanding that the Parties will collaborate to streamline processes and enhance efficiencies with the shared objective of reducing that figure over time as they mutually agree.

Informed Consent for Medical Procedure

Name and purpose of procedure(s): COVID-19 Nasopharyngeal Swab for PCR Testing for suspected exposure/infection by COVID-19 virus.

Description of Procedure: A nasal swab is gently inserted along the nasal septum, just above the floor of the nasal passage to the nasopharynx, until resistance is felt. The swab is left in place for several seconds to absorb secretions, rotated in place several times, and then slowly removing the swab while rotating it.

Potential risks of any procedure(s) include, but are not limited to, bleeding, infection, accidental injury to a nearby body part, incomplete repair, and death. Other reasonably common risks to this specific procedure(s) include: severe pain, nasal trauma, bleeding, or additional injury.

Benefits and expected outcomes: Adequate collection of nasopharyngeal specimens for COVID-19 PCR Testing, for diagnosis of suspected infection/screening of COVID-19 virus. I understand that this is not a consultation for care of suspected COVID-19 illness, neither evaluation nor treatment for possible complications of such infection. 

Alternatives, including, but not limited to: Testing by another service for anterior nare or saliva test, or rapid antigen testing, understanding that accuracy of results is variable.

I understand that the doctor(s) and/or his/her health associates may find unexpected conditions during the procedure(s) named above. An unexpected condition may require a change in procedure. I give my permission for the doctor(s) and/or his/her health associates identified on this form to either extend the planned procedure (do more) or do a different procedure, if she/he believes it is medically necessary for my health / health of the patient.

My questions about the procedure(s) have been answered to my satisfaction. I also understand that if I have more questions at any time before the procedure(s), I can call the Provider’s office at 201-503-4144. I have read and understand this consent form and all of the blanks were filled in before I signed it. By signing, I confirm to the best of my knowledge that the law allows me to consent to the procedure(s) for this patient.

This Agreement may not be assigned to any other person or entity by Patient. This Agreement replaces and supersedes all prior agreements of any kind, oral or in writing, regarding COVID-19 testing between Provider and Patient. This Agreement may not be modified absent a writing signed by Patient and Provider.

PATIENT ACKNOWLEDGES THAT HE/SHE HAS CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTANDS HIS/HER RESPECTIVE RIGHTS AND OBLIGATIONS UNDER IT, AND HAS SIGNED IT OF HIS/HER OWN FREE WILL AND VOLITION.

By signing below, Patient agrees to subscribe to Services as detailed above, as well as providing Informed Consent for the procedure. 

By signing below, I am voluntarily providing the specimen for analysis by laboratory. I authorize laboratory to release the test results to the ordering practitioner.