Informed Consent For Rapid Antigen Testing
Completion of this document authorizes the disclosure and/or use of your individually identifiable health information as set forth below, consistent with federal (HIPAA) and state law concerning the privacy of such information.
If you have a negative Antigen test, but you have symptoms of COVID-19, the negative result in the antigen could be wrong and should be repeated or you should get a PCR.
The COVID-19 test is voluntary (not required) and results will be given to you directly.
REPORTING OF TEST RESULTS:
The COVID-19 test results will be given to you directly OR you will be notified by email or text of your results.
RELEASE OF TEST INFORMATION:
Per Title 17 Section 2500 of the California Code of Regulations, cases of Coronavirus Disease 2019 (COVID-19), must be reported to the local health officer for the jurisdiction where the person resides.
You may request a photocopy of the lab result
You have the right to a copy of this authorization form
You understand that you have responsibility for finding your own treatment and discussing with your own doctor the significance of your testing. You may book an appointment for a consultation with a health care provider at: firstname.lastname@example.org . The cost for consultation is: $125 per 10-minute slot and will be charged upfront to reserve the MD time.
CONSENT FOR USE OF DATA FOR RESEARCH STUDIES:
As little is known about the epidemiology of COVID 19, you are agreeing that we can report your data in a non-identified (anonymous) summary form and collaborate with other researchers who are collecting data on this condition for no compensation. Samples may also be saved for future study looking at the characteristics of the assays being used.
Any test can be wrong, In other words, any test can have a false positive or false negative result. If you have a negative Antigen, but you have symptoms of COVID-19, the negative result in the PCR could be wrong and should be repeated or you should get a PCR.
RELEASE OF LIABILITY:
I agree to release Cosmos Health Solutions and its employees and subcontractors for any and all liability regarding anything related to the processing of samples, notification of results, actual test results, or any other unforeseen problem. I understand that the test being performed is not fully understood in terms of the accuracy and may have both false negatives or false positives.
CONSENT AND SIGNATURE:
I authorize Cosmos Health Solution to notify me of the test result and provide me with guidance for medical follow up. I authorize for physician or health care provider affiliated with Cosmos to have access to and disclose my test results to me. I consent to provide my phone number and email released to the local Health Department where I live if required by law.