WHAT YOU NEED TO KNOW TO BE INFORMED

ACKNOWLEDGEMENT OF 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 acknowledgement to participate in CityHealth UrgentCare’s COVID-19 Viral Testing program to undergo a test to be analyzed using FDA EUA (emergency use authorization) testing modalities.

If you have active COVID-19 symptoms, you should be evaluated by your health care provider.

1. 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.

2. 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 & Environment, 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.

3. 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 acknowledge to have my test taken and analyzed 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.

4. FDA Guidance. I understand that the FDA has approved the use of the City Health testing modalities under EUA guidelines.

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, or229E.

HIPAA Privacy Acknowledgement Form

Acknowledgement Regarding Use or Disclosure of Protected Health Information

I consent to CityHealth Urgent Care (healthcare provider) to disclose the protected health information provided below to the registered school district as legally authorized and/or required.

Extent of Authorization: I authorize the release of data collected and created as a result of the COVID-19 testing performed by CityHealth.

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

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