I hereby grant permission to Lab Diagnostics LLC to perform a COVID-19 as set forth below at my direction.
I authorize Lab Diagnostics LLC to obtain these screening results and email or electronically communicate them to me at the phone number or email address indicated in this Consent.
I agree to pay for the tests in full at the time of service. I understand that the testing has not been ordered by a physician and is being done for my own use and not for medical diagnostic or treatment purposes. Because the tests are not ordered by a physician, insurance coverage is not available, including Medicare or Medicaid. Lab Diagnostics LLC will not submit the tests to any insurance company for reimbursement. I certify that I will not seek reimbursement from Medicare, Medicaid, Tricare, or any other government insurer/payer for the tests performed by Lab Diagnostics LLC.
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.
I authorize a COVID-19 Test (or for my child's or legal dependent’s test). I understand, agree, certify, and authorize the following:
1. I am the undersigned individual, or the parent or legal guardian (if the patient is a minor or dependent) of the individual named below.
2. I understand that I have contracted with Lab Diagnostics LLC for the collection of my or my child/dependent’s specimen. I authorize Lab Diagnostics LLC to collect the specimen (nasopharyngeal swab) and their laboratory to perform analysis and testing on the specimen.
3. I understand that the processing of the specimen and results may take between 1 to 2 days.
4. I understand that I am not creating a patient relationship with Lab Diagnostics LLC by participating in testing and that Lab Diagnostics LLC shall not be deemed to be acting as an authorized medical provider. I understand that Lab Diagnostics LLC is merely performing testing and analysis for my specimen.
5. I understand that Lab Diagnostics LLC will provide me with the results via an online portal with unique identifiers that only I shall have the information for. I understand that the CDC and other health organizations may be notified of the results of my test, in accordance with State and Federal Law.
6. I authorize Lab Diagnostics LLC to release test results or other information necessary to process said results.
7. I understand that there exist risks of exposure when receiving testing and agree to hold Lab Diagnostics LLC harmless from all liability or claims.
8. I understand that Lab Diagnostics LLC shall process my results using highly accurate and reliable testing equipment but cannot guarantee with 100% certainty the accuracy of the testing. I understand that, as with any medical test, there exists the potential for false positives or false negatives.
By selecting below, I acknowledge that I have read and agree to this Consent Form, I acknowledge that I have read, understand, agree, certify, and/or authorize the information above and further agree to hold harmless Lab Diagnostics LLC and the State of Florida, Division of Emergency Management, including its employees, agents, and contractors from any and all liability and claims.
My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing have been explained to my satisfaction by a qualified health professional. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any other time.