Registration First name Last name Gender Male Female Other Ethicity Birthdate Phone number Email Address what is the name of your insurance company Member insurance # Please upload a picture of the front of your medical insurance card Please upload a picture of the back of medical insurance card Front of photo id Back of photo id Please upload a pic of the member holding photo ID (selfie) Recently exposed to covid 19? I have been exposed to COVID 19 or someone who tested positive for COVID 19 in the past 10 days. No GT Code/ PCR Code (Medical Staff) Your signature Disclosure / Concept By completing and submitting this form, I confirm that I am the appropriate individual to provide consent and A. I authorize collection and testing of my sample for respiratory illnesses including but not limited to COVID-19, whether for an individual test (e.g. individual antigen or PCR test) or for a routine respiratory illnesses safety check (pooled test). By signing this form, I am consenting to any of the following testing methods for me. I understand that the testing entity will determine which testing methods to use and may submit 2 samples for prevention of false results (false negatives/positives). More detail about test types is provided in Appendix A. a. Individual testing on symptomatic individuals: for when individuals present symptoms. b. Individual testing on close contacts (Test and Stay): for asymptomatic close contacts to be tested daily for at least five (5) days from the first day of exposure. c. Routine respiratory illness safety check (previously referred to as "pooled testing"): for routine testing by collecting a group of samples and performing tests on the group, for efficiency, with individual testing happening either on the same individual samples at the lab or on new samples from the individuals in the group. I understand that all sample types will be non-invasive, short nasal swabs or saliva samples. B. I understand that a routine respiratory illnesses safety check (previously referred to as pooled testing) may yield individual results, and that my individual results within a safety check may not be shared with me. However, I understand and agree that my personal health information and personally identifiable information may be entered into the testing provider's technology platform by third party individuals, to assist with tracking safety check testing and identifying individuals in need of individual follow-up testing. C. I understand that I will be notified about the results of any individual test for respiratory illnesses performed on me. D. I understand that there is the potential for a false positive or false negative respiratory illnesses test result, no matter the kind of testing being performed. Given the potential for a false negative, I understand that I should continue to follow all respiratory illnesses safety guidance, and follow protocols for isolating and testing in the event I develop symptoms of any respiratory illnesses. E. I understand that staff administering all COVID-19 testing have received training on safe and proper test administration. I agree that neither the test administrator , nor any of its trustees, officers, employees, or organization sponsors are liable for any accident or injuries that may occur from participation in the respiratory illnesses testing program. F. I understand that I should stay home if feeling unwell. I acknowledge that a positive individual test result is an indication that I must self-isolate, and continue wearing a mask or face covering as directed in an effort to avoid infecting others. G. I understand, the testing entity 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 I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand I am financially responsible for any care I receive from my healthcare provider. H. I understand that respiratory illnesses testing may create protected health information (PHI) and other personally identifiable information, and such information will only be accessed, used, and disclosed in accordance with HIPAA and applicable law. Pursuant to 45 CFR 164.524(c)(3), I authorize and direct the testing provider to transmit such PHI to the Department of Public Health, the Office of Health and Human Services, and the testing laboratory. I further understand that PHI may be disclosed to the Executive Office of Health and Human Services and any other party, as authorized under HIPAA. I. I understand that participation in COVID-19 testing may require to disclose my identity, demographic, and contact information to the Department of Public Health. J. I understand that authorizing these COVID-19 tests for me is optional and that I can refuse to give this authorization, in which case, I will not be tested. K. I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information previously released. To cancel this permission for COVID-19 testing, I need to contact info@equanimitymesolutions.com. Some Department of Public Health to monitor aspects of the respiratory illnesses, such as tracking viral mutations, by analyzing positive sample(s) for epidemiological and public health purposes. Results of such analyses will not be personally identifiable nor create personally identifiable information. L. The undersigned have been informed about the respiratory illnesses 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 sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for respiratory illnesses. Send
