TERMS AND CONDITIONS

By the act of booking the following tests I agree to all terms and conditions listed below:

I certify that this test is for myself, or that I am the guardian of a minor below the age of 18 seeking to take this test and that I am completing this enrollment on behalf of the minor.

I understand that, if I do not have an ordering provider, an independent ordering provider will be appointed to determine whether or not the test(s) are appropriate for me. AFC Urgent Care Bridgeport is one of these independent Partners in Care.

I authorize this independent ordering provider, and any collection personnel and the laboratory to conduct collection and testing for COVID-19 through a PCR test or a blood draw.

I am responsible for checking my email for results notification and logging on to my account to view my results when available.

I understand that after receiving my results, I will have the opportunity for a telemedicine consult with the independent ordering provider to answer any questions I may have.

I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by state, local and/or federal health agency in accordance with applicable law.

I acknowledge that a positive test result is an indication that I must self-isolate as directed by CDC recommendations in an effort to avoid infecting others.

I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

If I receive an abnormal result on a COVID-19 PCR Test and have not connected with the independent ordering provider, I understand that I am responsible for following up with my physician for care, diagnosis or medical treatment (or, if I am the parent or legal guardian of a minor who is providing the sample for testing, the minor’s pediatrician).

I voluntarily agree to this testing for COVID-19.


PRIVACY PRACTICES REGARDING HEALTH INFORMATION DISCLOSURE
The ordering provider and the laboratory will abide by all data privacy and other laws that apply to them, including HIPAA. They will use commercially reasonable best efforts to not disclose any individually identifiable health information, except for the following circumstances: to perform the services (including billing for such services); in case of emergency; for the purposes of contact tracing to inform others about their risks; and otherwise as permitted or required by law.


BILLING
The independent ordering provider will bill your insurance company (or yourself, if you selected to pay cash) for any applicable services included in the review and approval of your COVID-19 tests. The laboratory will separately bill your insurance company (or yourself, if you selected to pay cash) for the laboratory test. There is no financial relationship between the independent ordering provider and the laboratory.


DISPUTE RESOLUTION
In the event of any dispute, claim, question or disagreement arising from or relating to this consent, the parties hereto shall use their best efforts to settle the dispute, claim, question, or disagreement. To this effect, the parties shall consult and negotiate with each other in good faith and, recognizing their mutual interests, attempt to reach a just and equitable solution satisfactory to both parties. If the parties do not reach such solution within a period of thirty (30) days, then all disputes shall be resolved by binding arbitration in Connecticut, in accordance with the Commercial Arbitration Rules of the American Arbitration Association (the “AAA”), subject to the limitations herein. Notice of a demand for arbitration shall be filed in writing with the other party hereto and with the AAA. The demand for arbitration shall be made within a reasonable time after the dispute has arisen. The parties agree that one (1) arbitrator shall arbitrate the dispute. The arbitrator shall be selected by the joint agreement of the parties, but if they do not so agree within twenty (20) days after the date of the notice of a demand for arbitration referred to above, the selection shall be made pursuant to the Commercial Arbitration Rules of the AAA from the panels of business arbitrators maintained by the AAA. The decision of the arbitrator shall be made in writing, shall be final, judgment may be entered upon it in any court having jurisdiction thereof. The expenses of arbitration, including reasonable attorneys’ fees and the fees and expenses of the arbitrator, shall be shared equally by the parties.


GOVERNING LAW
All disputes arising out of or relating to this consent shall be governed by Connecticut law regardless of your country of origin, and notwithstanding of any conflicts of law principles.


PREP ACT LIMITATION OF LIABILITY
A new public health act, called the Public Readiness and Emergency Preparedness (PREP) Act, was issued by the Department of Health and Human Services in 2020. The PREP Act limits the legal rights of persons participating in certain covered countermeasures administered by covered entities. Covered countermeasures include testing to diagnose COVID-19, and covered entities include those administering COVID-19 tests. Therefore, the ordering provider and those assisting with supervising or administering this COVID-19 testing are immune from liability for any loss caused, arising out of, relating to, or resulting from administration or use of this COVID-19 test, except for claims involving willful misconduct.


WAIVER AND RELEASE OF LIABILITY
I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, and any minor or participant for whom I am consenting, hereby forever release, indemnify, and hold harmless the parties involved in providing this testing, which includes but is not limited to the independent ordering provider and the laboratory, any individual who extended this testing opportunity to me through their employment or relationship to the ordering provider and the laboratory, the property owner, landlord, and/or property manager of the site where testing takes place, any third-party clinicians operating the test collection site, as well as the associated affiliates, owners, investors, officers, and directors of the parties listed above, from liability and claims for damages or injury arising out of or in connection with any aspect of this COVID-19 testing, whether known or unknown, foreseen or unforeseen, except for claims involving willful misconduct.