RAPID BIOSENSE, LLC 

COVID-19 TESTING PATIENT CONSENT AND AGREEMENT

Rapid Biosense, LLC (referred to herein as “Lab,” “we,” “us,” and/or “our”) maintains the policies below with respect to COVID-19 testing (“COVID-19 Testing”). By signing this Patient Consent and Agreement, you agree to receive COVID-19 Testing from Lab and its employed, contracted, and affiliated healthcare providers.

1. Informed Consent for COVID-19 Testing. 
   1. You voluntarily consent and authorize Lab to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic laboratory test. 
   2. You acknowledge and understand that your COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab, oral swab, or other recommended collection procedures. 
   3. You understand and agree that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and, as with any medical test, there may be a potential for false positive or false negative test results. 
   4. You agree to assume complete and full responsibility to take appropriate action with regard to your test results. You acknowledge that a positive test result is an indication that you must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. 
   5. You authorize your test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. 
   6. You acknowledge and understand that the COVID-19 Testing equipment has not been approved by the U.S. Food and Drug Administration (“FDA”), but that it has been authorized by the FDA under an emergency use authorization for use by authorized  laboratories  and  patient  care settings, and  has been  authorized  only  for the  detection  of nucleic  acid from SARS-CoV-2, not for any other viruses or pathogens.

1. Release and Indemnification. You acknowledge that the Lab is not performing a complete physical examination and is not liable for civil damages as a result of acts or omissions in performing COVID-19 Testing services. You hereby expressly, fully and forever agree to release, waive, indemnify, discharge, and hold harmless Lab, its owners, managers, investors, directors, officers, representatives, affiliates, employees, and contractors (collectively, the “Indemnified Parties”) from, and covenant not to sue any Indemnified Parties for, any and all liabilities, claims, losses, judgments, damages, costs, demands or causes of action, including attorney fees, that you may have at any time for any reason resulting from or related, indirectly or directly, in whole or in part, to services rendered by Lab or the disclosure of my COVID-19 test results regardless of any sole, concurrent or contributory negligence, acts, omissions or fault of Indemnified Parties. This Section shall survive termination or expiration of this Patient Consent and Agreement.

Your signature below evidences your voluntary agreement to undergo COVID-19 Testing services and that you are the patient or are authorized to act on behalf of the patient to sign this Patient Consent and Agreement. By signing below, you agree that you have read, understand, and agree to all of the statements contained in this Patient Consent and Agreement. Your signature below further evidences that you have been informed about the COVID-19 Testing services and the purpose, procedures, possible benefits and risks, and that you have been given an opportunity to ask questions before you sign and have been told that you can ask other questions at any time. You understand that your agreement is effective on the date signed below and that you may revoke your agreement in writing. Your revocation will not be effective for actions already taken by Lab or that are in progress and will only be prospectively effective. 

Patient HIPAA Authorization

AUTHORIZATION: I hereby authorize Rapid Biosense, LLC (the “Laboratory”) to disclose to [insert employer’s / school’s / athletic club’s name] and its employees and contractors (collectively, “Recipient”) information relating to my laboratory tests and results including, without limitation, my COVID-19 related testing and results, in any and all formats or portions now existing or hereafter concerned (examples of formats are paper, digital, internet). 

This authorization will remain in effect for two (2) years after the date I discontinue receiving services from the Laboratory.  I understand that I have the right to revoke this authorization, in writing, at any time, except where uses and disclosures have already been made based upon my original consent.  Revocation must be communicated in writing to the Laboratory.

I understand that authorizing the disclosure of this information is voluntary.  I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or eligibility for benefits unless the information is necessary to demonstrate that I meet eligibility or enrollment criteria.  I understand I am entitled to a copy of this document in its complete form.  I understand that it is possible that information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.