Please read the disclaimer below.
As the parent/legal guardian of a minor student (“Student”), I hereby authorize and give my express consent to Northshore Clinical Laboratories for Student to be tested for COVID-19. I understand that a specimen will be collected from Student and tested for COVID-19 using a PCR Test.
I further authorize Student’s test results to be disclosed to authorized representatives at their respective school and to any applicable county, state, or other governmental entity as may be required by law, and understand that such disclosure will also be made consistent with applicable law.
I understand that potential benefits include that the testing results can help me, Student and Student’s healthcare provider make informed recommendations about Student’s care and may help limit the spread of COVID-19.
I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the organization which has arranged for the testing, and (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contract tracing). Protected heath information will not be reused or disclosed by Company to any person or entity other than the above, except as required by law.
This authorization and consent is valid until revoked in writing by the parent or legal guardian or is no longer necessary under the law. I have the legal authority, based on my relationship to Student, to consent to this test administration for the Student.
By signing below, I am agreeing to voluntarily testing. In signing this agreement, I acknowledge and represent that I have read it, understand it, and sign it voluntarily.