Please read the consent below.
1. I, on behalf of myself or my minor son/daughter/legal dependent (the “student”), authorize InnerHealth Laboratory (hereinafter “IHL”) and School they attend at the Irvine Unified School District to conduct collection and testing for exposure to the 2019 Novel Corona Virus (COVID-19) through a mid-turbinate nasal swab, saliva sample, or other minimally or non-invasive sample collection method as ordered by an authorized medical provider.
2. I acknowledge that, if the student receives a positive test result, I must ensure that the student abides by all applicable federal, state and/or local requirements with respect to isolation and quarantine to avoid infecting others.
3. I further acknowledge that, in the event of a positive test, IHL and/or individuals or contractors acting on its behalf, may contact me and those who may have been exposed to the student and the student’s identity may be disclosed to certain individuals to the extent necessary to protect the health and safety of those exposed.
4. I understand that by signing this document and agreeing that the student shall undergo COVID-19 testing, that I am not creating a patient relationship with IHL or school. I understand that IHL or school is not acting as a medical provider for the student. Testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regards to the test results for the student. I agree I will seek medical advice, care, and treatment from a medical provider for the student to the extent such medical advice, care and treatment becomes necessary.
5. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. A negative test result is not a 100% guarantee that you do not have a current COVID-19 infection and does not guarantee that you will not test positive for COVID-19 in the future.
6. I understand that Irvine Unified School District has engaged IHL to assist it in administering its COVID-19 testing program. I further understand that in order for the COVID-19 testing program to be successfully administered, certain personal information regarding the student will need to be communicated to such IHL for purposes of administering the program, and only to the extent necessary to the administration of the COVID-19 testing program. This includes certain information contained within personal identifiable information protected under the Family Educational Rights and Privacy Act, including student name, school, grade level, and cohort. I hereby expressly authorize such information regarding the student to be disclosed as described herein to the extent necessary to the administration of the COVID-19 testing program.
7. I understand that neither I nor my family will be charged directly for services. Third-party payment sources may be billed.
8. By signing this form, I acknowledge that I have received a copy of IHL Notice of Privacy Practices.
Medical records will be kept in a confidential manner; however, I acknowledge that IHL may release information regarding treatment to third party payors such as Medi-Cal or insurance companies for the purpose of billing. I also understand that public information such as immunization history and/or communicable disease may be shared with the school nurse to protect the health of other students. I understand information may also be disclosed to certified third parties to facilitate the transmission of electronic health records.
This authorization shall remain in effect until canceled in writing.