This notice of privacy provides information about how we may use and disclose protected health information about you. The notice contains a Patient Rights section describing your rights under the law. You have the right to review these Conditions before acknowledging this Consent
By accepting, you consent to our use and disclosure of protected health information about you for treatment. You have the right to revoke this Consent in writing signed by you. However, such revocation shall not affect any disclosures we have already made in compliance with your prior Consent. Veritas Testing, LLC its agents, officers, members and employees and its managed sites and physicians provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
:The patient understands
Protected health information may be disclosed or used for treatment, billing, health care operations and/or as required by law. I hereby authorize Veritas Testing to release any information from my test to WMI, any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize Veritas Testing to provide a copy of my medical records to my primary care physician (PCP) to allow for continuity of care
Protected health information may be disclosed or used for treatment, billing, health care operations and/or as required by law. I hereby authorize Veritas Testing to release any information from my test to WMI, any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize Veritas Testing to provide a copy of my medical records to my primary care physician (PCP) to allow for continuity of care
I fully understand the risks and benefits involved in participating in Covid-19 BD Veritor Antigen Test by Veritas Testing, LLC and I consent to having the screening performed. I have had all of my questions answered
I understand that this activity involves certain risks for physical injury. I also understand that there are potential risks of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules and regulations, and any supervisor’s instructions regarding participation in this activity
I understand that Veritas Testing, LLC, its agents, officers, members and employees and its managed sites and physicians does not insure participants in the above-described activity, that any coverage would be through personal insurance, and has no responsibility or liability for injury resulting from this activity
I voluntarily elect to participate in this activity with knowledge of the danger involved, and I hereby agree to accept and assume any and all risks of property damage, personal injury, or death
In consideration for being allowed to voluntarily participate in the above-referenced event, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever
Waive, release, and discharge the Veritas Testing, LLC, its agents, officers, members and employees and its managed sites and physicians from any and all negligence and liability for my death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event