I am at least eighteen (18) years of age. I voluntarily consent and authorize the 360 Clinic, and their partners, any of their respective officers, directors, employees, representatives and agents to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test for myself and/or my child(ren) and/or my legal dependent(s) as applicable. I recognize that I need medical services and I voluntarily consent to treatment by the medical staff of the practice, as deemed necessary in their judgment.
I understand that the type of test I am signing up for is a COVID-19 molecular reverse-transcriptase polymerase chain reaction [PCR] test to detect the presence of viral RNA. The test will consist of a self-collected nasal swab, or in some cases a self-collected oral swab.
I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19. I understand that test results are not 100% accurate and there may be a potential for false positive or false negative test results.
A positive molecular test for SARS-CoV-2 generally confirms the diagnosis of COVID-19; however, tests may remain positive long after a patient is no longer infectious due to prolonged detection of RNA.
A negative test result may just mean that I was not infected at the time the test was done. I understand that I could still become infected at a later point, so it is important to continue to practice prevention measures such as physical distancing and washing my hands frequently. If I continue to have symptoms associated with COVID-19, I will contact my medical provider.
I assume complete and full responsibility to take appropriate action with regards to my test results. If I have questions or concerns regarding my results, or my condition gets worse, I agree I will promptly seek advice and treatment from an appropriate medical provider.
I understand that the extent of the county's role will be determining whether the test is medically appropriate. Should I receive positive test results, I will seek care from my own medical provider.
The Patient acknowledges and consents to treatment by 360 Clinic using the telehealth practice platform for easier access to evaluating, testing and diagnosing my medical condition.
The Patient acknowledges and consents that such treatment will be made by a doctor, nurse, or nurse practitioner.
The Patient acknowledges and consents that billings and fee rates apply to telehealth as apply for in-person encounters, however co-pays have been waived by most insurance companies.
This consent is in addition to the general informed consent.
Having insurance is not required to receive a COVID-19 PCR test. If I have insurance information, I have provided this, accurately and completely and understand this information will be used to bill my insurance company for the cost associated with this test. I will not be charged for this test.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, without limitation, any of their 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 understand and agree that my COVID-19 test results may be sent to me by text message, telephone or email by a lab or third-party organization, and I authorize the disclosure of my COVID-19 test results to such organization. I understand and agree that my COVID-19 test results may be shared with a Health Information Exchanges (HIE). An HIE is a community-wide information system used by participating health care providers to share health information about you for treatment purposes. Should you require treatment from a health care provider that participates in one of these exchanges who does not have your medical records or health information, that health care provider can use the system to gather your health information in order to treat you. For example, he or she may be able to get laboratory or other tests that have already been performed or find out about treatment(s) that you have already received.
Your initial confirms that you consent to COVID-19 testing, and, if you have any of the symptoms, you will isolate yourself from any other people until you receive a negative test result.