(Please read the disclaimer below)
In consideration for receiving the opportunity to participate in COVID-19 testing (hereinafter “Testing”), which is provided by Ravinia Clinical Lab (the “Company”), I hereby release, waive, discharge, covenant not to sue, and to hold harmless for any and all purposes Company and their healthcare staff, members, shareholders, officers, servants, agents, volunteers, or employees (herein referred to as “indemnitees”) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney fees and expenses, that may be sustained by me while participating in Testing, while traveling to and from the Testing, or while on the premises owned, leased or occupied by Indemnitees.
I am fully aware that the Testing provided by Company may involve COVID-19 tests that have not gone through a full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending such processing and that the results could produce false positives or false negatives or be administered in a way that otherwise produces inaccurate results, or they are laboratory developed and shown similar performance to EUA authorized reagents. This test has been validated in accordance with the FDA guidance document (policy for diagnostics testing in laboratories certified to perform high complexity testing under CLIA prior to emergency use authorization for coronavirus disease-2019 during the public health emergency) issued on February 29th, 2020. I am also fully aware that the Company is not providing medical care or giving a medical diagnosis with Testing and that I should consult my doctor as to the results of Testing.
I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the organization which has arranged for the testing, (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contract tracing). Protected heath information will not be reused or disclosed by Company to any person or entity other than the above, except as required by law.
By signing below, I am agreeing to voluntarily test. In signing this agreement, I acknowledge and represent that I have read it, understand it, and sign it voluntarily.