COVID-19 Testing Intake Form

I understand that as part of my testing, LAB to YOU originates health records describing my test result. By clicking 'accept' I agree to the terms of the HIPAA Privacy Rule of Patient Authorization Agreement. I also give my permission for LAB to YOU to release my test results to other healthcare providers, my employer, and local, state and federal agencies.
Please carefully read and indicate acceptance of the following Informed Consent: I (or legal guardian for minors) authorize this COVID-19 testing unit to conduct collection and testing for COVID-19. I authorize my test results to be disclosed to the county, state, or to any other government entity as may be required by law. 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 by applicable government mandates and guidelines in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider; this testing does not replace treatment by my medical provider; and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns about this test or the results therefrom, or if my condition worsens. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, LAB to YOU LLC, 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. I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I click Accept, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19. I specifically assume the risk of testing and agree to release and waive any claim arising from my selection to receive this voluntary screening. I fully indemnify LAB to YOU for any, and all costs it may incur as a result of any claims with respect to my testing.
Certain infectious diseases, conditions, and the identity of those who test positive for them, are required by federal, state or local regulations has to be reported to local or state health authorities by LAB to YOU LLC. 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 states list of reportable conditions, including but not limited to COVID-19, my test results and my identifying information will be reported to the applicable local, state and/or federal health authority. Additionally, I understand that if I test positive for any infectious disease or condition, neither LAB to YOU LLC, their staff, or the third-party testers that run the 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 healthcare provider.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Print Name*
Relationship if signing on behalf of patient

Testing Consent*
- I understand that test results reported by LAB to YOU LLC will be reported directly to me in the manner I have chosen above. I further understand that it is my responsibility to consult my own medical professional for the interpretation, analysis, evaluation, and explanation of my test results. I also understand that my results will be disclosed to my employer if I am an employee with a company using testing to determine safe work environment.
- I agree that LAB to YOU LLC, its members, managers, employees, independent contractors, directors, staff, physicians, or its other agents shall not be liable for any claims associated with my testing, including but not limited to, any claim arising out of or related to, inaccurate, un- interpreted, misinterpreted or results not received and do hereby, for myself and my heirs, expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action. This release includes inability to work or losses incurred due to quarantine requirements as well as all future medical expenses incurred, as result of my positive or false positive test results. I acknowledge I have been informed that no test is 100% accurate.
- I understand that the tests performed at LAB to YOU LLC are done at my request to be screened through either blood, nasal samples, oral fluid, or other testing matrix.
- I understand that the test results may become part of my medical record. I also understand that an insurance company may discover the results of this test by obtaining a copy of my medical record in accordance with the terms of my insurance policy(ies).
- I understand that the test being administered involves a nasal swab that will be tested to indicate the potential presence of COVID-19. This type of test is known as the "Rapid Test" using shallow nasal swabs and with results typically received in less than thirty minutes (based on volume and other factors). I understand that there is also a deep test which uses deep swabs and where results may take longer to receive but may be more reliable. I consent to the use of the Rapid Test and assume all risk and responsibility for the results therefrom.
- I have read and agree to all the above terms.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Print Name*

Client COVID-19 Testing Intake Form