DISCLAIMER:
INFORMED CONSENT FOR COVID-19 DIAGNOSTIC TESTING
1. Authorization and Consent for Covid-19 Diagnostic Testing:
I understand that falsifying information on this form is criminal offence. I voluntarily consent and authorize our National Covid Prevention and our supporting clinical laboratory to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from my Primary Care Provider (PCP) or, a health care provider.
2. Patient Rights and Privacy Practices
Disclosure to Government Authorities: I acknowledge and agree that our supporting clinical laboratory may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
3. Release
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, supporting clinical laboratory, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.
By selecting the ACKNOWLEDGEMENT during the registration process for COVID-19 Diagnostic Testing at our supporting clinical laboratory, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19
Medical insurance coverage
4. Insured Patients
If it is found that you have medical insurance and you select “NO Insurance” you will be held liable for payment.
I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the organization which has arranged for the testing, and (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contact tracing). Protected health information will not be reused or disclosed by Company to any person or entity other than above, except as required by law.
By signing below, I am agreeing to voluntarily testing. In signing this agreement, I acknowledge and represent that I have read it, understand,and sign it voluntarily.