General Consent
I authorize ARCpoint Labs, ARCpoint Franchise Group, AFG Services, and its affiliated companies and laboratories (“ARCpoint”) to collect specimens for the purpose of obtaining the tests I have selected. I understand that the type of test determines the type of specimen that will be collected. Some tests require nasal swabs, oral swabs, blood, urine and/or saliva specimens. There are possible risks and discomforts associated with collection of specimens.
Any testing performed by or through ARCpoint is only for my personal use. The tests that are provided are not intended for medical, diagnostic, or treatment purposes, and may not be eligible for insurance reimbursement. Physician NPIs or diagnosis/ICD10 codes will not be provided.
If I have selected a COVID-19 test, I understand that there is a risk of false positive or false negative test results. I understand I should continue to protect against the spread of COVID-19, including use of a mask, social distancing, frequent hand-washing and other recommendations by the CDC and my state DOH. I will contact my healthcare provider and monitor my condition if I develop symptoms, regardless of my test results, and will comply with public health requirements such as quarantine.
I understand that ARCpoint is not acting as a medical provider and that no provider-patient relationship is created with ARCpoint through this testing. I will take appropriate action regarding my test results, and obtain advice, care and treatment from my healthcare provider as appropriate.
Acknowledgement of Privacy Practices
By signing this form, I acknowledge I have been made aware of the Notice of Privacy Practices of ARCpoint available at https://www.arcpointlabs.com/our-privacy-policy/. The Notice of Privacy Practice provides information about how ARCpoint uses and discloses protected health information. I agree ARCpoint and its contractors, including but not limited to Rymedi may collect, retain, use and disclose my personal information, including demographic and health information, as necessary to provide the requested services as described in the Privacy Policy for ARCpoint and the laboratories that perform the requested testing. I also agree my information may be used for related purposes including payment, operations, and other purposes permitted by law.
I agree that ARCpoint and its contractors, including the laboratories performing the requested tests, may communicate with me via the contact information I provide with this test request, including any email address, phone number, or address, about the tests I have requested, test results, and billing and payment for the tests. Pre-recorded messages, artificial voice messages, automated telephone dialing devices, and other computer-assisted technology may be used to communicate with me.
I authorize ARCpoint Labs to provide my laboratory results directly to me at the e-mail address I have provided. I also understand that it is my responsibility to notify ARCpoint Labs of any change in this information.
I understand that I may revoke this authorization by sending written notice to the ARCpoint Labs location in which my test was performed. I understand that if I revoke this authorization, it will not have any effect on the disclosures made prior to ARCpoint Labs receiving my written notice of revocation.
I understand that ARCpoint Labs and its affiliates are not Medicare participating providers and do not contract with any payer. I also understand that even if the labs to which my specimens are sent for testing are enrolled in Medicare, no claims will be submitted to Medicare, Medicaid, or any other payer for the services herein, and the tests and services provided are not eligible for reimbursement by Medicare, Medicaid or any other government-related insurer or government-related payer.
I agree to be financially responsible for full payment for any and all testing and other services provided by ARCpoint and its affiliates and contractors. I understand that I may have the right receive these services elsewhere from a Medicare participating provider or a provider in-network with my health coverage plan or insurance and receive covered services at little or no cost to me. Notwithstanding those possibilities, I have chosen to receive and be fully financially responsible for the services performed by ARCpoint and its affiliated labs and contractors.
I understand that this authorization will remain in effect until I send written notice that I revoke this authorization to the ARCpoint location where I received services.
Reportable Conditions
Certain infectious diseases, conditions, and the identity of those who test positive for them, are required by federal and/or state law to be reported to local or state health authorities by ARCpoint Labs, its affiliates, members of their respective clinical staffs, and any third-party laboratories conducting the laboratory tests. The time frames and reporting requirements vary according to the disease or condition.
Accordingly, I understand that if I test positive for any infectious disease or condition on the state’s list of reportable conditions, including but not limited to COVID-19, my test result and my identifying information will be reported to the applicable local or state health authority.
Additionally, I understand that if I test positive for any infectious disease or condition, neither ARCpoint Labs, their staff, or the third-party laboratories that run the laboratory tests, will diagnose, treat, prescribe medications, or refer me for medical treatment. It is my sole responsibility to seek and comply with necessary treatment and all required follow-up with my physician, healthcare provider, or local public health department.
I AGREE THAT NEITHER ARCPOINT LABS NOR ITS DIRECTORS, STAFF, HEALTH CARE PROVIDERS AND/OR AFFILIATED LABS (ARCPOINT) SHALL BE LIABLE FOR ANY CLAIM, LIABILITY OR DAMAGES ARISING OUT OF OR RELATED TO THE TESTING, INCLUDING BUT NOT LIMITED TO, INACCURATE, UN-INTERPRETED, MISINTERPRETED RESULTS OR RESULTS NOT RECEIVED AND DO HEREBY ON BEHALF OF MYSELF, MY ESTATE, MY HEIRS AND ALL OTHERS EXPRESSLY FOREVER RELEASE, DISCHARGE, AND HOLD HARMLESS ARCPOINT FROM SUCH CLAIMS, LIABILITIES OR DAMAGES. I AGREE THIS RELEASE AND HOLD HARMLESS SHOULD BE ENFORCEABLE TO THE FULLEST EXTENT PERMITTED BY APPLICABLE LAWS.
By signing below, I affirm that I have read this Informed Consent. I understand and agree that the testing is for my personal use only, that no provider-patient relationship is created, that I must consult with my healthcare provider regarding the interpretation of test results, and that the test(s) may not be eligible for insurance reimbursement. I understand the test purpose, the procedure for obtaining the specimen, the possible risks and benefits, and I have had the opportunity to ask my healthcare provider any questions. I voluntarily agree to the tests I have requested and agree to pay the amounts indicated.