COVID-19 Testing: Laboratory Consent
1. I authorize Ananda Analytical Laboratories to run requested COVID diagnostic
testing. I authorize Ananda Analytical Laboratories, LLC to receive payments for this bill from my health insurance. With this assignment of benefit, I know I am responsible for the full payment, copayment, co-insurance, or deductibles. If the insurance pays me for the services, I will send the checks to Ananada Analytical Laboratories, LLC.
2. I authorize the release of medical information necessary to process the claim and act as my power of attorney for request of appeal and documents. I further consent to and authorize the release of my results and related health information to the party designated on this for COVID-19 Testing.
1. I authorize testing for COVID-19, through a nasopharyngeal swab or blood draw, asordered by an authorized medical provider or public health official.
2. I authorize my test results to be disclosed to the county, state, or to any other
governmental entity as may be required by law.
3. I acknowledge that a positive test result is an indication that I must self-isolate
and/or wear a mask or face covering as directed in an effort to avoid infecting others.
4. I understand that the medical provider who performed the screening is not acting as my primary medical provider, this testing does not replace treatment by my primary medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my primary medical provider if I have questions or concerns, or if my condition worsens.
5. I understand that the specifc medical provider who performed the screening and her employer or legal entity which she represents or has an ownership interest in, cannot be held responsible for any inaccurate test result that may be generated by the screening or testing procedures. I understand that in signing this Informed Consent, I am agreeing to hold the medical provider and any employer or entity for which she has an ownership interest free and harmless from potential liabilities. This means that I cannot sue themedical provider or her employer or any entity in which she has an ownership interest if the test results are not accurate.
6. I, the undersigned, have been informed about the test purpose, procedures, possible benefts, and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.
COVID-19 Testing: Release of Information
1. I authorize Ananda Analytical Laboratories, LLC to release the following healthcare information: Laboratory Reports. The purpose of disclosure is for safe participation in school activities, athletic events, and work site. Ananda Analytical Laboratories, LLC is hereby released from all legal responsibilities or liability for the release of the above-mentioned information. Notice: Fees may apply for copies of your records. Unless required by law, California law prohibits the recipient from further disclosing your health information unless recipient obtains another authorization from you. If you have authorized the disclosure of your health information to someone who is not legally required to keep it
confidential, it may no longer be protected by state or federal confidentiality laws.
C.F.R. §§ 160.103and 164.512 (b) (1)(v).
2. Your Rights: I understand that I have the right to withdraw this authorization at anytime, except for action already taken, and that such revocation must be in writing to the Health Information Department at the address: 17881 Sky Park Circle, Irvine, Ca USA.Expiration: This authorization of release of healthcare information for treatment provided after this date of signature or if such treatment occurs while this authorization has not expired. If there is no expiration date given, this authorization will expire one year from the date of signature.