INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING

Please carefully read the following informed consent:
  1. I authorize Jordan Valley Community Health 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 Jordan Valley Community Health Center or any member of the Jordan Valley Community Health Center by receiving a COVID-19 test. I understand that Jordan Valley Community Health 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"), Jordan Valley Community Health Center, MAKO Medical Laboratories, LLC; and any entity with which Jordan Valley Community Health Center or MPCA may contract to communicate my test results to me. I acknowledge that I have been given a copy of Jordan Valley Community Health 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 Jordan Valley Community Health 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 Jordan Valley Community Health Center to provide my test results to me verbally or in any other written or electronic format Jordan Valley Community Health Center deems appropriate.