This document is for reference purposes only. It is intended to provide general guidance, is not legal advice and is not a statement regarding any standard of care. This document does not take into account every law or requirement of federal, state or local authorities which may be applicable to you or your practice site(s).
I also understand that the novel corona-virus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that all the staff at Olympus Health and Performance are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of requiring close contact to proceed with this elective procedure. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective procedure, and I give my express permission for Drs. Larson and Sawyer and all the staff at Olympus Health and Performance to proceed with the same.
Specifically regarding COVID-19 PCR testing, the 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel is a real-time PCR test intended for the qualitative detection of nucleic acid from the 2019-nCoV in upper and lower respiratory specimens (such as nasopharyngeal or oropharyngeal swabs) collected from individuals who meet 2019-nCoV clinical and/or epidemiological criteria (for example, clinical signs and symptoms associated with 2019-nCoV infection, contact with a probable or confirmed 2019-nCoV case, history of travel to geographic locations where 2019-nCoV cases were detected, or other epidemiologic links for which 2019-nCoV testing may be indicated as part of a public health investigation). COVID-19 PCR testing in the United States is limited to laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) 42 U.S.C 263a, to perform high complexity tests.
Results are for the identification of 2019 n-CoV RNA. The 2019 nCoV RNA is generally detectable in upper and lower respiratory specimens during infection. Positive results are indicative of active infection with 2019 nCoV but do not rule out bacterial infection or co-infection with other viruses.
The agent detected may not be the definite cause of disease. Laboratories within the United States and its territories are required to report all positive results to the appropriate public health authorities. Negative results do not preclude 2019-nCoV infection and should not be used as the sole basis for treatment or other patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.
I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that possible exposure to COVID-19 during my procedure may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my testing, and depending on the results, I may need additional care that may require me to go to an emergency room or a hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the procedure.
I have been given the option to defer my testing to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired procedure.
In the event that testing is administered in conjunction with a third party or offsite location, liability is waived for the third party or offsite location in conjunction with your testing.
Consent for Use and Release of Information
I give permission to OHP – including their treating and referring providers and other staff members – to release any information about me, my health, the health services provided to me, or payment for my health services, that may be necessary: (1) for my treatment (to health care providers or facilities that need the information for my continued care); (2) for any purposes related to payment by me or a third party for services (to determine eligibility, to process an insurance claim, for utilization and quality review, or for billing or collection purposes, as necessary to obtain payment); or (3) as required by law. I consent to the release of information relating to the COVID-19 IgG/IgM Rapid Testing and/or COVID-19 PCR testing to be given to any employer designated by me. I further authorize such release as follows:
No payment shall be due at time of treatment for non-insured or insured patients. If I have not provided current or accurate insurance information, I am responsible for payment of all charges. I understand that if I do not provide insurance information or falsify insurance information it is medical fraud and payment and penalties by CMS will be billed to patients. For non-insurance patients, OHP will bill to the Federal COVID-19 Uninsured Program. OHP will bill insurance on behalf of patient. If there are any issues obtaining reimbursement from the insurance carrier, OHP will be responsible for the cost. The patient will not be responsible if reimbursement is unobtainable, which is known as back billing. OHP will accept payments for mobile fee charges (if a mobile fee applies for offsite testing) in the following manner: (i) Company checks; (ii) certified funds; (iii) credit card payments; or (iv) HSA accounts (through HSA authorized debit cards).
Sharing Information with Family or Friends
As a courtesy, limited health information may be shared with family and friends under the following conditions: (1) the information is related to that individual’s involvement in the patient’s care or payment for care, or (2) the information is needed to notify individuals responsible for the patient’s care about the patient’s location, general condition or death. Unless I have initialed below, I give permission for limited health information to be shared with my family and friends under the conditions mentioned above.
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE TEST(S) I AM REQUESTING.
Today's Date: October 20, 2020