We are required to collect the below information by New York State law (PBH 576-c, Title 10 58.14, (EO) 202.61). Please fill out to the best of your ability.
Please write "NA" if not applicable
A) By providing my electronic signature, I voluntarily consent and authorize: VABER COVID TESTING NYC (Herein knows as “VABER”) to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. B) I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab, or other recommended collections procedures. C) I authorize my test results to be disclosed to the county, state, or any other governmental entity as may be required by law. D) I understand that testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree that I will seek prompt 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 are Risks and Benefits of undergoing a diagnostic test for COVID-19; and there may be a potential for either false positive or false negative results. F) To the fullest extent permitted by law, I hereby release, discharge and hold harmless, "VABER", including, without limitation, any of its respective officers, directors, employees, representatives and agents from any claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results. G) By signing this consent form, I acknowledge and agree that I read, understand, and have agreed to the statements contained within this form. I have been informed about the purpose of this COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided the opportunity to ask questions before I sign and proceed with this COVID-19 diagnostic test. I have been told I can ask other questions at any time. H) Upon completion of my test(s), I hereby acknowledge and will accept all associated charges to my credit/debit card and will not dispute said charges with my financial institution. I) I understand that some services are not always covered by my insurance company based on medical necessity. J) I understand that I will have to contact my insurance company directly to see if they will either fully or partially cover the SARS CoV-2 test that I will be taking at VABER COVID Testing NYC. K) I understand that if any treatment is rejected by my insurance plan as a non-covered procedure or service, I will be financially responsible for those services. L) I acknowledge as a member of my insurance plan(s) that this office will provide me with an itemized receipt including the diagnostic code of your test for submission to your insurance company if applicable. I understand that I will be responsible for paying all fees at the time of the visit.