INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING

Please carefully read the following informed consent:
  1. I authorize Central Ozarks Medical Center to conduct collection and testing for COVID-19 through a nasopharyngeal, oropharyngeal, nasal mid-turbinate or anterior nares swab (a swab inserted into my nose).

  2. I understand that I am not creating a patient/provider relationship with Central Ozarks Medical Center or any member of the Central Ozarks Medical Center by receiving a COVID-19 test. I understand that Central Ozarks Medical Center is not acting as my medical provider and that testing does not replace treatment by my medical provider.

  3. I take full responsibility to take appropriate action with regards to my test results when I receive them. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns after I receive the test, or if my condition worsens.

  4. I understand that I and my health insurance carrier will incur no costs associated with a COVID-19 test performed related to this Informed Consent.

  5. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

  6. By signing a HIPAA Authorization in conjunction with the Informed Consent, I further authorize my test results to be disclosed to the State of Missouri, Department of Health and Senior Services; Coalition for Primary Health Care dba Missouri Primary Care Association ("MPCA"), Central Ozarks Medical Center, MAKO Medical Laboratories, LLC; and any entity with which Central Ozarks Medical Center or MPCA may contract to communicate my test results to me. I acknowledge that I have been given a copy of Central Ozarks Medical Center's Notice of Privacy Practices.

  7. I acknowledge that a positive test result is an indication that I must self-isolate in an effort to avoid infecting others.

  8. I understand that there is the potential for false positive or false negative test results.

  9. I, the undersigned, have been informed about the COVID-19 test purpose, procedures, possible benefits and risks, and I have received a copy of the 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.

  10. I understand that I have to set up a Mako electronic patient portal account and that it is the only option to receive timely reporting of COVID test results. I also understand if Mako cannot provide my test results to me via the electronic patient portal account, I may need to contact Mako by telephone to receive my results. I further authorize Central Ozarks Medical Center to provide my test results to me by way of text messages to the above mobile number and authorize use of the phone number I provided for receipt of medical information. In addition, I authorize Central Ozarks Medical Center to provide my test results to me verbally or in any other written or electronic format Central Ozarks Medical Center deems appropriate.