COVID-19 Test Online Registration Form - University High School
COVID-19 QUESTIONNAIRE
You are receiving this questionnaire as part of a COVID-19 testing program arranged by Irvine Unified School District. Our company, OneHealth Telemedicine, LLC, employs physicians, who will review this information in order to approve your COVID-19 test. The answers to these questions are confidential and protected by HIPAA. No confidential information will be shared with your school district without your written consent. All information is stored securely. BEFORE YOU START, IF YOU ARE EXPERIENCING ANY OF THESE SYMPTOMS, STOP AND CALL 911: Constant chest pain or pressure- Extreme difficulty breathing- Severe, constant dizziness or light-headedness - Slurred speech- Difficulty waking up
Patient Name
*
First Name
Last Name
Parent/Guardian Name (enter na if you are the patient)
*
First Name
Last Name
What is your gender?
*
Male
Female
Other
What sport does student play?
*
Football
Water Polo
Basketball
Volleyball
Wrestling
Cheer
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number (We call or text results to you. It is important to give us your correct cell phone number)
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth (MM/DD/YYYY)
*
Do you have insurance?
*
Yes
No
Insurance Plan (required):
*
Member ID# (required):
*
Social Security # (required if you do not have insurance):
*
State ID or Drivers License # (required if you do not have insurance):
*
Height - Feet & Inches
*
Weight
*
I identify my ethnicity as:
*
Asian
Black or African American
Caucasian
Hispanic or Latino
Native American
Pacific Islander
Other
Prefer not to say
Do you have any of the following conditions?
*
Asthma or chronic lung disease
Pregnancy
Diabetes with complications
Diseases or conditions that make it harder to cough
Kidney failure that needs dialysis
Cirrhosis of the liver
Weakened immune system
Congestive heart failure
None of the above
Have you or anyone in your household had any of the following symptoms in the last 21 days?
*
Fever of greater than 100 degrees Fahrenheit
Chills or sweating
Shortness of breath for unknown reasons
New or worsening cough
Sore throat
Aching through the body
Vomiting or diarrhea
Headache
Loss of taste or smell
None of the above
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
*
Yes
No
Are you or anyone in your household a health care provider or emergency responder?
*
Yes
No
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for Covid-19?
*
Yes
No
Have you or anyone in your household been tested for Covid-19?
*
Yes
No
What is your exposure to others who are known to have COVID-19?
*
I live with someone who has/had COVID-19
I've had close contact with someone who has COVID-19
I've been near someone that has COVID-19
I work or attend school in an environment where others have tested positive for COVID-19
Acknowledgment
OneHealth Telemedicine, LLC: Telemedicine Informed Consent Form:
I hereby consent to engaging in telemedicine with OneHealth Telemedicine, LLC, “the practice,” as part of my treatment. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in California. I understand that I have the following rights with respect to telemedicine: (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my visit is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent. (3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that telemedicine-based services and care may not be as complete as face-to-face services. I also understand that if my provider believes I would be better served by another form of services (e.g. face-to-face services) I will be referred to a provider who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of treatment, and that despite my efforts and the efforts of my provider, my condition may not be improve, and in some cases may even get worse. (4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. (5) This consent will remain valid for six (6) months from the date of my first telemedicine visit with the practice.
*
I understand and acknowledge.
Please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
*
First Name
Last Name
PHYSICIAN-PATIENT ARBITRATION AGREEMENT
Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether my medical services under this contract were necessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and now by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitrationArticle 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against the physician, the amount of damage sought, and the names, addresses and telephone number of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration should be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§1 – 4). The parties shall bear their own costs, fees, and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by physician not only after the date it is signed (including but not limited to emergency treatment), but also before it was signed as well.Article 5: Revocation: This agreement may be revoked by written notice delivered to physician within 30 days of signature and if not revoked, will govern all medical services received by the patient.Article 6: Severability Provision: In the event any provision(s) of this agreement is declared void and/or unenforceable, such provision(s) shall deemed severed therefrom the remainder of the agreement enforced in accordance with California law.
*
I understand and acknowledge.
Please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
*
First Name
Last Name
HIPAA Requirements
All patients have certain rights to privacy regarding their protected health information. These rights are given to them under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Treatment (including direct and indirect treatment by other healthcare providers involved in my treatment); obtaining payment from third party payers (e.g. my insurance company); the day-to-day health care operations of your practice. All patients will be informed of, and given the right to review and secure a copy of their Statement of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. We reserve the right to change the terms of this notice from time to time and when contacted will disclose it to our patients. All patients have the right to request restrictions on how their protected health information is used and disclosed to carry the treatment, payment, and health care operations, but that they are not required to agree to these requested restrictions. All patients may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date they revoke this consent is not affected. Your physician understands the importance of patient confidentiality and is committed to the protection of your personal health information. All personal identification information is protected and stored on a secure server. All information given via the physician consult form or in a conversation with any of our employees is held in complete confidence. Our employees adhere to the strict standards for patient confidentiality set by the American Medical Association and the Health on the Net Foundation. We do not share any of your personal information with any of our affiliate or associate sites. We will not release any personally identifying information to anyone unless mandated by federal or state laws. Aggregate statistical summaries may be released to third parties, but these statistics will contain no personally identifiable information.
Due to the Covid-19 Pandemic, we are experiencing a high level of calls and requests for tests. The fastest and easiest way to receive results is through text message and/or email. BY SIGNING BELOW, YOU ALSO AGREE TO RECEIVE LAB RESULTS ELECTRONICALLY VIA TEXT MESSAGE OR EMAIL.
*
I understand and acknowledge.
Parent/Guardian, please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
*
Parent/Guardian First Name
Parent/Guardian Last Name
Back
Next
Authorization to Release Patient Information
I hereby authorize the following organization to release diagnostic lab results from COVID-19 and related virus tests, including results from IgG/IgM antibody, PCR naso swab, or RPP naso swab tests. No other patient information other than you COVID-19 test results will be released to your employer. Information to be released from: OneHealth Telemedicine, LLC, 5000 Birch Street, West Tower, Newport Beach, CA 92660, Phone: 949-545-8738. Information to be released to: Irvine Unified School District, Attn: Athletic Director, 5050 Barranca Parkway, Irvine, CA 92604
AUTHORIZATION: This authorization may be revoked at any time except to the extent already relied upon, and will expire in 1 year from the date of signing unless previously revoked. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under privacy laws.
I understand and acknowledge.
Parent/Guardian, please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
Parent/Guardian First Name
Parent/Guardian Last Name
Back
Next
Laboratory Consent Form:
Billing ABN and patient Plan Information: A completed Advance Beneficiary Notice (ABN) of coverage is required for Medicare patients who do not meet medical criteria for testing. This does not apply to specific sit analyses. Insurance pre-qualification will not be performed for these tests, unless specifically requested. All tests ordered shall be processed and billed based on payor.
Patient Acknowledgement: I am covered by insurance and authorize Ayass BioScience, LLC to give my designated insurance carrier(s) plan on this form and other information provided by my health care provider necessary for reimbursement. I authorize Ayass BioScience, LLC to inform my plan of my test results only if test results are required for preauthorization of or payment for reflex/additional testing. I authorize Plan benefits to be payable to Ayass BioScience, LLC. I further authorize payment of benefits directly to the laboratory. I understand that any payment I receive for services rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory.
Patient Consent: My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing have been explained to my satisfaction by a qualified health professional. I have been given the opportunity to ask questions before I sign, and have been told that I can ask questions at any other time.
Patient Consent for Research: Remaining part of my sample can be used for research purposes by Ayass BioScience, LLC. Personal information will not be shared and will be kept confidential by Ayass BioScience, LLC.
AUTHORIZATION: This authorization may be revoked at any time except to the extent already relied upon, and will expire in 6 month from the date of signing unless previously revoked.
*
I understand and Acknowledge
Parent/Guardian, please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
*
Parent/Guardian First Name
Parent/Guardian Last Name
Back
Next
Authorization to Participate in Inter-Team Competition
In partnership with LFN Corporate Wellness, OneHealth Telemedicine and Acme Genomics, our school will provide all football and water polo players and coaching staff with a weekly salvia PCR COVID-19 test. Test results will be available 24-hours after administration. The first test will be administered to players on Monday, March 1, 2021. All future testing for both football and water polo teams will be conducted at your child’s school on Mondays.
We are excited for a safe return to athletic competitions. However, we also recognize that participation in football and water polo are identified as a higher-risk activity and want to provide you the choice in your child’s participation in competitions. Therefore, we are asking all parents of football and water polo parents to indicate their preference for your child’s participation. Regardless of parental choice, all student-athletes will continue to be rostered on the team.
Your signature below indicates your understanding that due to the nature and risk of COVID-19 transmission while participating in Outdoor High-Contact and Moderate-Contact sports. We are asking that you indicate your preference for your child’s participation. Bus/van travel for members of a team may pose a greater risk. To mitigate COVID-19 transmission risk during travel, students will need to self-transport to competitions. Please note it is recommended by CDPH that travel by private car be limited to only those within the immediate household. Immediate household members of athletes are permitted to observe inter-team competitions. Spectators will be limited based on the ability to ensure physical distance can be maintained and reduce potential crowding. Spectators must wear a face mask while on school grounds. Failure to comply will result in removal from the competition. Your signature below indicates your agreement to adhere to the spectator guidelines.
AUTHORIZATION: This authorization may be revoked at any time except to the extent already relied upon, and will expire in 6 month from the date of signing unless previously revoked.
*
Yes, my child may participate in inter-team competition
No, my child may not participate in inter-team competition
*
I understand and will adhere to the spectator
Parent/Guardian, please type your full name. I agree this electronic signature will have the same legal effect as a handwritten signature.
*
Parent/Guardian First Name
Parent/Guardian Last Name
Submit
Should be Empty: