I voluntarily consent and authorize Vitality Urgent Care to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through CDC authorized collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider or contact Vitality Urgent & Primary Care for consultation.
I consent to Vitality Urgent Care and subcontracted entities (“Company”) administering the test and collecting information from me as required for testing administration and by the Coronavirus Aid, Relief and Economic Security Act, including name, date of birth, address, gender, race, and ethnicity (“My Information”).
I understand that COVID-19 PCR positive test results also will be disclosed to the applicable Public Health authorities and such Public Health authorities may contact me directly
I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. 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 additional questions at any time. I voluntarily agree to this testing for COVID-19.
I understand the testing unit is not acting as my primary medical provider, this testing does not replace treatment by my primary 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 primary medical provider if I have questions or concerns, or if my condition worsens.
I understand that I am entitled to receive a copy of this Consent once it has been signed and can request my COVID-19 PCR test results directly. If I have questions about the testing, its procedures, possible risks or benefits, the alternatives, or my rights, I can contact Company at (224) 601-5001.
I allow Company to disclose my personal health information, including my COVID-19 PCR test results to my Employer only for purposes of performing functions related to communicable disease prevention, control, and containment, including alerting others with whom I have come into contact of possible exposure to COVID-19, monitoring the workplace, and activities related to maintaining a safe work environment. I understand that my test results may identify me by name, date of birth, or other identifying information.
I can revoke this Authorization at any time by notifying Company in writing at Vitality Urgent and Primary Care, 1807 Hick Rd, Suite A, Rolling Meadows, IL 60008 , and I understand that doing so will prevent future disclosures but will not affect my employer the ability to use information they received before the revocation. The consent is valid for 1 year from the first testing date.
AUTHORIZATION TO RELEASE RESULTS TO EMPLOYER
I authorize to release test results to employers on testing results only.
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
I authorize to use and disclosure of my personal information for the purposes of diagnosing or providing treatment to me, obtaining payments for my care, or for the purposes of conducting the health care operations of the practice. I also authorize Vitality Urgent Care to release any information required in the process of application for financial coverage for the services rendered. This authorization provides that the practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agents. If it is the case that my insurance company utilizes a managed care company, my therapist may need to discuss my treatment with a case manager. I understand that my confidentiality will be compromised in such a case. I realize that his/her doing so is a necessity in his effort to secure ongoing care.
- Do I need to make an appointment for urgent care visit?
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