RAPID ANTIBODY AND PCR OR ANTIGEN SWAB TEST - Compass Care

RAPID ANTIBODY AND PCR OR ANTIGEN SWAB TEST

Rapid Antibody and PCR or Antigen Swab Test

First Name
Last Name
Phone Number
Address
Email
City
Zip Code
State
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
Sex
  • - select a option -
  • F
  • M
Ethnicity
DOB
Race

Signature / Responsible Party (If under 18) I. hereby authorized Eazy Testing and its affiliated partners to receive payment and authorize the release of medical information necessary to process this claim and act as my power of attorney for request of appeal and documents.

Patient Signature

HIPPA Compliance Patient Consent Form



Our Notice of Privacy Practices prvodies information about how we may use or disclose protected health information. The notice contains a patient's rights section section describing your rights under hte law. You ascertain that by your signature that you have reviewd our notice before signing this consent.



The terms of the notice may change, if so you will be notified at your next visit to update your signature/date.



You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restrictions, but if we do, we shall honor this aggrement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information of the information for treatment, payment, or healthcare operations.



By Signing this form, I understand that:



Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The pratice has the right to restrict the use of the information but the pratice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email or send a text to you to confirm appointments?
May we discuss your medical condition with any member of your family?
Parent Name if Under 18
May we leave a message on your answering machine at home or on your cell phone?
If YES, please name the members allowed:
Patient Signature
Do you live in a group home, assisted living center or other facility with more than 3 other people older than 60 years old?
  • - select a option -
  • Yes
  • No
Do you work in a hospital, long-term care facility or assisted living facility?
  • - select a option -
  • Yes
  • No
Have you traveled anywhere outside of your state in the past 1 month?
  • - select a option -
  • Yes
  • No
Have you been in close contact (i.e. within 6 feet) with someone confirmed to have COVID-19?
  • - select a option -
  • Yes
  • No
Please mark the symptoms you are currently experiencing:
Consent

Please carefully read the following informed consent: a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official. b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as maybe required by law. c. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others. d. I understand that I am not creating a patient relationship with EAZY Testing Inc by participating in testing. I understand the testing uniti s not actin gas my medical provider. 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 or concerns, or if my condition worsens. e. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. f. I acknowledge that I have been given a copy of Compass Care Testing's Notice of Privacy Policy. I, the undersigned, have been informed about the 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 other questions at any time. I voluntarily agree to testing forCOVID-19.The local health jurisdiction has determined that if you are under suspicion for havingCOVID-19 due to symptoms and testing request, that it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public’s health. Thank you for agreeing to cooperate. 2. Please carefully read and comply with the following statements: a. I understand that I may be infected with the virus causing COVID-19 and that I meet criteria for isolation. b. I agree that while I wait for my COVID-19test results, I will remain in self-isolation. c. I agree that if my COVID-19 test results are positive, I will remain isolated for 7 days from this day of testing OR until at least 72 hours after my symptoms have resolved, whichever is longer. d. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after my symptoms have resolved. e. I understand that if I am not isolated while ill, I could pose a substantial threat to the health of other persons. f. I agree that I will not come into contact with any other person who is not isolated or ill due to potential COVID- 19 infection. I, the undersigned, have been informed about the 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 other questions at any time. I voluntarily agree to testing for COVID-19 and to self-isolation.

Patient / Parent Signature
Other People to be Tested
Enter the names of other people to be tested. Each person must complete a seperate form.
Test Type
Patient Chart
Client Number
Physician Number
Test Code
Diagnosis Code
Insure ID
Collection Time
Collection Date
Insurance Number
Source