WNY Rapid Testing

First Name

Middle Initial

Last Name

Suffix

Date of Birth

Parent/Guardian Name

Gender

Race

Ethnicity

Are you pregnant?

Home/Cell Phone Confirm Home/Cell Phone

Work Phone

Email Address

Confirm Email Address

Marketing Consent

Keep me updated about products and services from WNY Rapid Testing LLC via:

E-Mail

Yes

Text Message/SMS

Yes

Home Address

Street Address

Street Address Line 2

City

State/Province

Zip/Postal Code

Employer Information

Employer name

Employer phone

Employer address

Employer city

Employer State/Province

Employer Zip/Postal Code

Job title

School Information

School role

School district

School name

Notice of Privacy Practices Acknowledgement

        I understand that this authorization includes my consent for medical testing

        I understand I am financially responsible for payment of services provided during this visit and payment is due at time of service.
        
        Certain lab tests may be sent to an independent lab for processing. I understand that I may or may not receive a separate bill for these services.

        In general, the HIPAA Privacy Rule (Health Insurance Portability and Accountability Act of 1996 - Federal Law) gives individuals the right to request a restriction of uses and disclosures of their Protected Health I nformation (PHI). It also provides the right to request confidential communicatio ns between an individual and his/her physicians office.
        
        To protect your privacy and in keeping with the Federal Privacy Law, all of your medical information, PHI, is kept strictly confidential. We will use this PHI for treatment, payment, and operations (TPO) of our medical practice. We will be required to get an authorization in writing from you if we intend to use your PHI for any other purpose.

I acknowledge receipt of the Notice of Privacy Practices of our facility, give Authorization to Treat, and acknowledge your Financial Responsibility.

Coronavirus Testing Consent

        a. I consent WNY Rapid Testing LLC, a COVID19 testing organization, to conduct collection and testing for COVID19 via nasal and/or nasopharyngeal swabs as well as capillary and/or venous blood collection as ordered by an authorized medical provider or public health official.

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

        c. I acknowledge that a positive test result is an indication that I must self isolate and /or wear a mask or face covering as directed in an effort to avoid infecting others.

        d. I understand WNY Rapid Testing is not acting as my medical provider, this testing does NOT replace treat ment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
        
        e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID 19 test result.

I agree to the above "Coronavirus Testing Consent"

I certify that, to the best of my knowledge and belief, the information provided here is true and correct.