COVID-19 RAPID drive-thru PCR Testing

COVID-19 TESTING PATIENT CONSENT AND AGREEMENT

Marking the checkbox below evidences your voluntary agreement to undergo COVID-19 Testing services and that you are the patient or are authorized to act on behalf of the patient to sign this Patient Consent and Agreement. By signing below, you agree that you have read, understand, and agree to all of the statements contained in this Patient Consent and Agreement. Your signature below further evidences that you have been informed about the COVID-19 Testing services and the purpose, procedures, possible benefits and risks, and that you have been given an opportunity to ask questions before you sign and have been told that you can ask other questions at any time. You understand that your agreement is effective on the date signed below and that you may revoke your agreement in writing. Your revocation will not be effective for actions already taken by Lab or that are in progress and will only be prospectively effective.

Patient HIPAA Authorization

AUTHORIZATION: I hereby authorize Blue Ocean Lab Services (the “Laboratory”) to disclose to [insert employer’s / school’s / athletic club’s name] and its employees and contractors (collectively, “Recipient”) information relating to my laboratory tests and results including, without limitation, my COVID-19 related testing and results, in any and all formats or portions now existing or hereafter concerned (examples of formats are paper, digital, internet).

This authorization will remain in effect for two (2) years after the date I discontinue receiving services from the Laboratory.  I understand that I have the right to revoke this authorization, in writing, at any time, except where uses and disclosures have already been made based upon my original consent.  Revocation must be communicated in writing to the Laboratory.

I understand that authorizing the disclosure of this information is voluntary.  I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or eligibility for benefits unless the information is necessary to demonstrate that I meet eligibility or enrollment criteria.  I understand I am entitled to a copy of this document in its complete form.  I understand that it is possible that information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.