CONSENT AND RELEASE
Last Updated: Oct 12, 2021
1. I hereby give consent to modMD to administer (“Testing”) the COVID‑19 PCR Test (“Test”) and to provide medical diagnosis of the Testing results and related services (“Additional Services”), as provided by modMD, PC (“modMD”) at my direction or at the direction of a party that has engaged or employed me (“Employer”), and further authorize modMD to release my protected health information (namely Covid-19 test results) to my Employer if performed at their direction.
2. I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless modMD and its healthcare staff (including but not limited to independent contractors and their employees administering the Test), members, shareholders, officers, agents, contractors, volunteers, and/or employees and my Employer (where applicable), from any and all liabilities, claims, demands, injuries (including, without limitation, personal injury, death and lost wages, salary and employment), or damages, including, without limitation, court costs and attorney’s fees and expenses, that may be sustained by me as a result of the Test, Testing, Additional Services, and/or Test, Testing, and/or Additional Services provided by modMD to others, including, matters of negligence and strict liability.
3. I agree that modMD has communicated to me the risks and benefits associated with the Testing that I am agreeing to undertake and I have had an opportunity to ask a member of modMD’s staff any questions I have on the risk associated with the Testing to which I am submitting. Knowing each of those risks, I am agreeing to be proceed with the Testing from modMD. I understand that this authorization may apply to multiple or recurrent Testing and/or ongoing Additional Services.
4. I am fully aware that the Testing provided by modMD may involve COVID‑19 tests that have not gone through a full FDA approval process (and have instead obtained emergency FDA authorization) and that the results could produce false positives or false negatives, or be administered in a way that may produce inaccurate results. I am also fully aware that modMD is not providing medical care and only providing a medical diagnosis based on the results indicated from Testing and that I should consult my doctor or go to an emergency room, if I have any serious symptoms and/or to obtain medical advice regarding the results of the Testing. If the Testing produces a negative result, it does not exclude the possibility that I have COVID‑19 or that I may develop it in the future, and I am aware that I should obtain further testing if I develop any symptoms or come in contact with anyone who, I become aware, may have or been exposed to someone who has COVID‑19. I choose to voluntarily participate in Testing with full knowledge of these facts. I know of no medical reason why I should not participate.
5. I understand that my express consent is required to release any protected health information relating to testing/diagnosis, and/or treatment for COVID-19. If I have been tested for COVID-19, you are specifically authorized to release all health care information relating to such testing, including the release of Covid-19 test results to my Employer if performed at their direction, as indicated by my initials here.
6. This disclosure is made at my request. I understand that authorizing the disclosure of this health information is voluntary. I understand I have the right to revoke this authorization in writing. I understand the revocation will not apply to information that has already been released in response to this authorization. To revoke an authorization, I may write a letter to modMD. I understand that once the health information I have authorized to be disclosed reaches the specified recipient, that person or organization may re-disclose it, at which time it may no longer be protected under applicable privacy laws. I understand that the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease. I understand that this authorization may apply to multiple or recurrent testing and the related Covid-19 test results. I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment, or enrollment).
7. Where I have provided a debit/credit card for payment, I hereby give modMD permission to charge the stated fees for testing services. I acknowledge that the fees, once charged, are non-refundable.
8. This authorization will expire two years from the date of signing. A copy or facsimile of this signed authorization shall be counted true and valid as original.
Date: ____________________________
Participant Signature: ____________________________
Printed Name: ____________________________
Date of Birth: ____________________________
Phone Number: ____________________________
Email: ____________________________