Informed Consent Agreement

Informed Consent Agreement for Testing

Please carefully read the following informed consent in its entirety.

COVID-19 is an infectious illness caused by a newly discovered coronavirus. For many, the illness is mild or does not produce symptoms; however, some others, including the elderly and those with underlying medical problems (such as heart disease, diabetes, chronic respiratory disease, cancer, and others) are more likely to develop a serious illness that may result in hospitalization or even death. We are offering you the voluntary opportunity to take a COVID-19 test to help you keep yourself and others safe by not further spreading the virus.

Streptococcus Group A ("strep throat" or "strep") is a bacterial infection that can make your throat feel sore and scratchy. Strep throat accounts for only a small portion of sore throats.

Respiratory syncytial virus (RSV) causes infections of the lungs and respiratory tract. It's so common that most children have been infected with the virus by age 2, but the virus can also infect adults.

The flu is a common respiratory illness you get from the influenza virus. Symptoms often include fever, head and body aches, coughing and a stuffy or runny nose.

By selecting the ACKNOWLEDGEMENT checkbox during the registration process for Diagnostic Testing, I agree to the following:

  1. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing related to my symptoms.
  2. I authorize and the site testing unit to conduct collection and testing related to the COVID-19 virus through a nasopharyngeal swab or saliva test or COVID-19 antibodies testing through a simple blood test or other tests through their required means.
  3. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law or local department of health.
  4. I understand that, as with any medical test, there is the potential for false positive or false negative test results due to many different potential reasons.
  5. I acknowledge that a positive test result is an indication that I may need to start or continue to self-isolate and/or wear a mask or face covering as directed by my medical provider in an effort to avoid infecting others.
  6. I understand that I am not creating a patient relationship with this testing unit by participating in testing. I understand that and the testing unit is not acting as my medical provider and this testing does not replace treatment by my medical provider. 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 medical provider if I have questions, concerns, if my condition worsens, or anything related to the testing process.
  7. To the fullest extent permitted by law, I hereby release, discharge and hold harmless,, First Call PPE LLC, MD Medical Group LLC, including, without limitation, any of its respective officers, partners, directors, employees, representatives, businesses, joint venturers, and agents from any and all claims, losses, costs, fees, liability, litigation and settlement costs, counsel fees, and damages, of whatever kind or nature, arising out of or in connection with any: 1) act or omission or negligence whatsoever, regardless of the merit or outcome, relating to my diagnostic test or the disclosure of my test results; 2) false positive or false negative test result that I receive; and 3) reliance by me on my test results and any actions or inactions I may take in reliance on my test results.
  8. I have been informed about the purpose of the diagnostic test, procedures to be performed, potential risks and benefits, and associated costs.
  9. I authorize, First Call PPE LLC, and MD Medical Group LLC to release all necessary information to my insurance carrier, and I assign payment of my medical benefits to and its affiliates. If my insurance company sends payments directly to me, I will return said funds to and its affiliates.
  10. I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I will be provided an opportunity to ask questions before proceeding with a diagnostic test and I understand that I can ask any question I want at any time for any reason.
  11. I understand that if I do not wish to continue with the collection, testing, or analysis of a diagnostic test, I may decline to receive continued services.
  12. I acknowledge, confirm and attest to the fact that I have the full authority to book the testing appointment on behalf of myself and/or on behalf of any other individuals for whom I am scheduling an appointment and that such other individuals have given me the authority to book a testing appointment on their behalf. I further confirm and attest that if the test results for other individuals for whom I have booked an appointment are being released directly to me that I have such other individuals' permission and prior approval to receive such test results and will provide a copy of such test results to those individuals immediately upon receipt. To the extent that I am signing up a minor for testing, I attest and affirm that I am the parent or legal guardian of such minor individual and have the right to provide informed consent on behalf of such minor. I further confirm that by scheduling an appointment for another individual other than myself, and pursuant to this Informed Consent Agreement, I am waiving on behalf of myself and any individuals for whom I schedule testing, any and all claims, losses, costs, fees, liability, litigation and settlement costs, counsel fees, and damages, of whatever kind or nature, against and First Call PPE LLC and MD Medical Group LLC, including, without limitation, any of its respective officers, partners, directors, employees, representatives, businesses, joint venturers, and agents, arising out of or in connection with the transmittal or disclosure of test results and including but not limited to any alleged violations of the Health Insurance Portability and Accountability Act (HIPAA). I further attest and confirm that I have provided any other individuals for whom I have scheduled a testing appointment with a copy of this Informed Consent Agreement and/or instructed them to review it prior to arriving for their testing appointment.
  13. The answers and information I have provided when booking an appointment for myself or any others is truthful.
  14. I authorize to charge my credit card (for self pay) or bill my insurance (for direct insurance billing) and conduct the collection, testing, and any required reporting. I understand that my appointment booking is subject to availability and all credit card charges are final. In the event a refund is authorized by in writing, there will be a 5% convenience and refund fee subtracted from any refund amount. In the event that my insurance denies the claim, i understand that I am fully responsible for all charges as outlined in the Patient Financial Responsibility Statement.
  15. I agree to allow and First Call PPE LLC to communicate with me for my test results, future testing, follow ups, or any other reason and that I will receive my results via the email address or cell phone number provided during the registration process. I also understand that it is possible for incorrect reporting results mistakes to happen and will confirm the results sent to me by reviewing the photo of my results attached.

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