WHAT YOU NEED TO KNOW TO BE INFORMED

VOLUNTARY TESTING FOR COVID-19

** DISCLAIMER: COVID-19 A NEW VIRUS. THERE CONTINUES TO BE MANY

VARIABLES AND UNKNOWNS. **

The purpose of this form is to obtain your voluntary consent to participate in CityHealth Urgent Care’s COVID-19 Viral Testing program to undergo a simple test to be analyzed using SARS-CoV-2 Viral PCR Testing. The goal of providing this service is to mitigate the spread of COVID-19 by frequently testing.

Important aspects of participating in this proposal:

Your participation is entirely voluntary. You may choose not to participate without there being any negative effect on you. Your sample will be given an anonymous sample identification number, pursuant to the laws of the State and in accordance with HIPAA compliant consent forms and the proper medical release forms.

CITYHEALTH INFORMED CONSENT FORM

I AM INFORMED. I received and read CityHealth’s informational sheet regarding their use of the SARS-CoV-2 Viral Test. I understand that my participation is entirely voluntary, and if I choose not to participate, there will be no negative effects on me.

Personal Information Privacy. I understand that all test results may be shared seamlessly in real time with designated personnel and risk management through the use of HIPAA compliant consent forms, medical release forms and utilizing secure, cloud-based file share software. HIPAA compliance will also be met through use of a Business Associates Agreement (BAA). However, under no circumstance will any of my personal information be made available or disclosed.

Personal Information Privacy and Use of Results with CityHealth and Medical Professionals. I understand that my test results may be provided to the County Public Health and appropriate professionals (including but not limited to the California Department of Public Health, on a need to know basis and as directed by HIPAA. The purpose of this need to know sharing of my results is for the limited purpose of informing medical providers so they may advise me on appropriate medical treatment and for limiting the spread of communicable diseases. My personal information will not be shared with anyone else.

Assumption of Risk and Release. I recognize that there are certain inherent risks associated with having my test taken for analysis. I hereby consent for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily agree to have my test taken and analyzed by Predicine Labs Inc., and hereby waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this activity, and do hereby release and forever discharge CityHealth, and their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, economical or emotional loss, that I may suffer as a direct result of my participation in this activity, including traveling to and from any location related to this activity. In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Indemnification. I agree to indemnify and hold harmless CityHealth, and their affiliates, managers, members, agents, attorneys, staff, volunteers, 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.

Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic (oral or nasal swab) should be considered to rule out infection in these individuals.

Results from this testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.

Positive results may be due to past or present infection with non-SARSCoV- 2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.

I agree to voluntarily participate in the COVID-19 testing, which will require subsequent tests and proper observance of your County’s Shelter in Place Order or other COVID-19 related health mandates. I have been informed about this testing and have had a chance to ask questions, to which were answered to my satisfaction. I further understand the benefits and risks of this test and consent to the testing.

COVID-19 Test Kit Activation

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(510) 984-2489

13690 E 14th St., Suite 100 San Leandro, CA 94578

1300 Clay St St., Suite 165Oakland, CA 94612

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13690 E 14th St., Suite 100
San Leandro, CA 94578

1300 Clay St St., Suite 165
Oakland, CA 94612