Please review cancellation in the consent terms below before booking.
Upon arrival to your test, please remain in your car and text the office at (860) 469-5646 with your name and car.
If you are planning on seeking reimbursement from your insurance, the codes are provided above and will be provided in an itemized receipt as well which will be attached to your lab results. You will need to check with your insurance whether reimbursement for all or some services will be provided.
Option to Receive Results Via Text Informed Consent. For convenience and speed, we provide the option for patients to receive their results as an attachment via text message as opposed to a patient portal message at the number included in this registration document. If you choose to receive results via text, you understand and acknowledge that communications with 4E DPC using e-mail, facsimile, video chat, instant messaging, and/or cell phone are not guaranteed to be secure or confidential methods of communication. As such, you hereby expressly waive 4E DPC’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. Patient understands and acknowledges that all such communications may become a part of his/her medical records. By providing acknowledging below you authorizes 4E DPC to communicate with you by text message regarding your "protected health information" (“PHI”) (as that term is defined in HIPAA). If you do not receive a response to an e-mail message or text within one (1) business day, you agree to use another means of communication to contact 4E DPC. 4E DPC expressly disclaims any liability associated with any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to you as a result of any action, inaction or activity outside the control of 4E DPC or technical issues within 4E DPC control, including but not limited to (i) technical failures attributable to any Internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail, text and video chat messages, (iii) failure of 4E DPC’s computers or computer network, or faulty telephone or cable data transmission, (iv) any interception of e-mail, text or video chat communications by a third-party; or (v) Patient’s failure to comply with the guidelines regarding use of email communications set forth in this consent.
Consent. I consent to, acknowledge, and understand that my COVID-19 test ("Test") will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. The test has been authorized by the FDA under an Emergency Use Authorization. I understand that there are risks and benefits associated with undergoing a test for COVID-19 and there may be a potential for false positive or false negative test results. I understand that there is a possibility of error and that a negative result does not exclude the possibility of COVID-19 and additional tests may be required since SARS-CoV-2 RNA was not present in my specimen above the limit of detection. I relinquish 4 Elements Direct Primary Care from any and all injury, physical or psychological, which might arise from collecting and testing these specimens and from any effects or actions that the results of these tests may have on me or any other concerned individual. This agreement for testing is subject to and shall be enforced in accordance with the laws of the State of Connecticut. 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. I furthermore understand that this test is a one-time occurrence and by obtaining this test, this visit in and of itself it does not establish an ongoing doctor-patient relationship, and I will seek subsequent medical care with my primary care provider, an urgent care center, or the emergency department at a local hospital.
Payment Policy. 4 Elements Direct Primary Care LLC (4E DPC) does not accept insurance for the test., and does not participate in Medicare or Medicaid programs. Testing services purchased through this website are solely my financial responsibility. Payment is required at time of booking. 4E DPC does not submit any claims directly to insurance, but they can provide itemized receipts 1-day after my test, with all appropriate codes and information needed for an easy submission experience. For medical claims, I must contact my insurance carrier for a claim form. 4 Elements Direct Primary Care will provide me with a receipt with information that will be helpful to me in submitting my claim. Reimbursements are at the discretion of my insurance carrier. Per the Medicare Opt-Out Agreement below, Medicare and Medicaid beneficiarie are not eligible to submit claims for reimbursement.
4 Elements Direct Primary Care LLC does not guarantee insurance reimbursement, and only provides one standardized form of receipt. I will be sure to check my out-of-network benefits summary or call my insurance company directly to verify my coverage and benefits for out of network COVID-19 testing. If I am filing an insurance claim, I will ensure that my insurance company is instructed to pay me directly. Should 4E DPC receive a check on my behalf, it will be returned and the check will have to be reissued to me by my insurance company.
Cancellation Policy. Please understand that appointment times are limited. If you must cancel your appointment, we require 48 hours notice, and your appointment will be refunded with the exception of $10 to cover credit card transaction fees. Missed appointments, or appointments cancelled without 48 hours notice will incur a fee in the full amount of the requested service.
Test Result and Consent to Disclose. I understand that 4 Elements Direct Primary Care LLC may release my test results to my primary care medical provider as noted below in this form without needing any additional release document. I understand that 4E DPC reserves the right to provide identified or in some cases de-identified information of statistical nature to Government agencies and reserves the right to use such anonymous information for validation and research purposes. By signing below, I consent to the disclosure of COVID Test to public health authorities as requested, recommended or required by federal, state, and local public health authorities.
Disclaimer to Treat. 4 Elements Direct Primary Care LLC has been engaged for the sole limited purpose of providing a Test and disclaims any obligation to treat me or provide me with any medical care. I have the right to discuss the Test with my own physician, to learn about the purpose, potential risks and benefits of any testing. Based upon my test results, I will contact my physician or other medical professional for advice and medical care.
Waiver of Liability and Indemnification. By signing below, I, on behalf of myself, my heirs, executors, administrators, assigns, or personal representatives agree to forever release and waive any claim arising from my selection to receive this Test or the disclosure of my test results that may arise against 4 Elements Direct Primary Care LLC and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns. Additionally, I agree to forever release and waive any claim that might arise against Everpoint and staff members for any risks, side effects, or complications resulting from the Test or the disclosure of my test results. I agree to indemnify and hold harmless 4 Elements Direct Primary Care LLC and their affiliates, managers, members, agents, staff, heirs, representatives, predecessors, successors and assigns against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.
Medicare Opt-Out Agreement. The Balanced Budget Act of 1997 allows physicians to “opt out” of Medicare and enter into private contracts with patients who are Medicare beneficiaries. In order to opt out, physicians are required to file an affidavit with each Medicare carrier that has jurisdiction over claims that they have filed (or that would have jurisdiction over claims had the physicians not opted out of Medicare). In essence, the physician must agree not to submit any Medicare claims nor receive any payment from Medicare for items or services provided to any Medicare beneficiary for two years. This Agreement between 4 Elements Direct Primary Care ("4EDPC") and me is intended to be the agreement physicians are required to have with Medicare beneficiaries when physicians opt-out of Medicare. This Agreement is limited to the financial agreement between 4E DPC and Patient and is not intended to obligate either party to a specific course or duration of treatment. I understand that 4E DPC and its Physicians have not been excluded from participation under the Medicare program under section 1128, 1156, 1892, or any other sections of the Social Security Act.
As part of this agreement, 4E DPC agrees to the following:
As part of this agreement, I agree to the following:
I have been given a copy of the Notice of Privacy Practices which I can access here: Notice of Privacy Practices 01/01/2022
By Signing in the box below I am stating the following: I understand that my personal information and test results will be shared with the Connecticut State Department of Public Health. I understand if the person being tested is under 18 years old, a parent or guardian must be present at testing. I understand that the results of the Accula SARS-CoV-2 RT-PCR Test should not be used as the sole determination of the presence or absense of the Covid 19 Virus. I understand that negative results could be a false negative and that I should confirm the negative result with another lab analyzed high completixty test for diagnostic purposes. I consent to being tested by 4 Elements Direct Primary Care CLIA ID 07D2175270 and confirm that I am at least eighteen years of age or signing for a minor under the age of eighteen.