Brophy College Prep

Please carefully read and sign the following informed consent: I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider, this does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. By selecting "I Accept", I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.

The local health jurisdiction has determined that if you are under suspicion for having COVID-19 due to symptoms and testing request, that it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public's health. Thank you for agreeing to cooperate. By selecting "I Accept", I agree to each of the following statements. I understand that I may be infected with the virus causing COVID-19 and that I meet criteria for isolation. I agree that while I wait for my COVfD-19 test results, I will remain in self-isolation. I agree that if my COVID-19 test results are positive, I will remain isolated for 7 days from this day of testing OR until at least 72 hours after my symptoms have resolved, whichever is longer. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after my symptoms have resolved. I understand that if I am not isolated while ill, I could pose a substantial threat to the health of other persons. I agree that I will not come into contact with any other person who is not isolated or ill due to potential COVID- 19 infection.

I request and authorize a CLIA certified laboratory to perform a COVID-19 test(s) on the samples provided by me. My signature or that of my witness below constitutes my acknowledgement that I have been informed by the benefits and limitations of this testing, which have been explained to my satisfaction by a qualified health professional. l hereby authorize my provider to release personal information, consistent with HIPPA, to Premier Lab Solutions to include billing, audits, and other purposes. I agree to obtain and submit a valid Advanced Beneficiary Notice (ABN) signed by the beneficiary and/or insuree for any test that is not supported by a diagnosis that meets Medicare or commercial payers limited coverage/medical necessity requirements.