I Need a COVID-19 Test

Diagnostic Testing

Consent and Authorization

I. Diagnostic Test Consent

By selecting “Accept” below, I agree that e3Health Solutions, LLC, doing business as eTrueNorth and its independent contractors (collectively, “eTrueNorth”) may provide the individual who is registered (the “Testing Recipient”) with one or more diagnostic tests (collectively “Tests”) capable of diagnosing the novel coronavirus disease (“COVID-19”) and/or the influenza A and influenza B viruses (together, the “Flu”). Also, I acknowledge that the Testing Recipient will self-administer the Tests, and I permit eTrueNorth to arrange for the analysis and interpretation of the Tests once the Tests contain the Testing Recipient’s specimen. Finally, in the event that Testing Recipient obtains a positive result on a Test from an applicable pharmacy that offers treatment services, I acknowledge that, if applicable, either a pharmacy or a physician may order and dispense appropriate antiviral medications, as determined pursuant to their independent professional judgement, in order to provide treatment to the Testing Recipient.

In addition, I understand and agree to the following:

1. I certify that either one of the following is true: (i) that I am the Testing Recipient and I am at least eighteen (18) years of age, or (ii) that I am the parent, guardian, or other legally authorized individual of the Testing Recipient who is legally authorized to provide consent on behalf of the Testing Recipient.
2. The Testing Recipient’s eligibility to receive the Tests will depend on objective, scientifically determined eligibility criteria established by the Centers for Disease Control and Prevention (“CDC”).
3. The Testing Recipient will self-administer the Tests.
4. The Tests may be analyzed and interpreted by one or more of eTrueNorth's contractors.
5. If Testing Recipient receives a positive Test result from an applicable pharmacy that offers treatment services, then, if applicable, (i) either a pharmacy or a physician may, using their independent professional judgement, order antiviral medications for the Testing Recipient, and (ii) a pharmacy will dispense such antiviral medications to the Testing Recipient, in order to provide treatment to the Testing Recipient.

II. HIPAA Authorization

I hereby consent to and authorize (i) the disclosure of the Testing Recipient’s completed Tests to eTrueNorth's contractors to permit analysis and interpretation of the Tests, (ii) the disclosure of the Testing Recipient’s protected health information (including, without limitation, a Testing Recipient’s appointment information) with any pharmacy in eTrueNorth’s pharmacy network, (iii) if applicable, the use and disclosure of Testing Recipient’s protected health information with any pharmacy in eTrueNorth’s pharmacy network and/or any physician for the purposes of providing the Testing Recipient with medical treatment in connection with any positive Test result (including, as applicable, antiviral medications), and (iv) the disclosure of the Testing Recipient’s Test results in any manner permitted by federal or state privacy and security laws. This consent and authorization is valid as of the day this document is signed by me and expires after one (1) year.

In addition, I understand and acknowledge the following:

1. I understand that I have the right to revoke this consent and authorization (except for the provisions set forth in Article III) at any time that I so choose by notifying eTrueNorth. If I revoke this consent and authorization, I understand that the revocation would only apply after I notify eTrueNorth.
2. I understand that my consent and authorization will result in the use or disclosure of the Testing Recipient’s protected health information. Though precautions will be taken to protect the confidentiality of this protected health information, I understand that the transmission of protected health information presents risks and that the confidentiality of such information may be compromised by failures of security safeguards or illegal tampering.
3. I understand that I may receive a copy of this consent and authorization by accessing “INeedaCovid19test.com” or by calling (800) 635-8611.

III. Billing Authorization

I understand that if I do not have health insurance, eTrueNorth will seek to obtain reimbursement via the Center for Disease Control and Prevention’s Increasing Community Access to Testing for COVID-19 program (the “ICATT program”).

If I do have health insurance, however, I understand that eTrueNorth will seek to obtain payment from my insurance carrier, I understand that I am liable for any amounts that my insurance carrier does not pay, and I voluntarily agree to the following authorization:

1. I hereby authorize and direct my insurance carrier to issue payment to eTrueNorth for any Test that Testing Recipient receives. To the extent applicable, I agree to pay for any amounts not covered by insurance.
2. I acknowledge that I voluntarily requested a Test from eTrueNorth on behalf of the Testing Recipient, and I understand that by making this request I am fully financially responsible for any charges associated with such Test.
3. I authorize eTrueNorth to (i) release any information necessary to insurance carriers regarding my Tests and health status; and (ii) process insurance claims generated in connection with my receipt of the Tests.

IV. Waivers

In consideration for receiving the opportunity to obtain the Tests and considering that the Tests are self-administered, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE eTrueNorth and its officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “eTrueNorth Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE ETRUENORTH RELEASEES OR OTHERWISE, THE TESTING RECIPIENT SELF-ADMINSTERING THE TESTS OR THE TESTING RECIPIENT’S PRESENCE ON SELECTED RETAIL PHARMACY GROUP’S PROPERTY TO OBTAIN THE TESTS. On behalf of the Testing Recipient, I hereby accept and assume all risks involved in the Testing Recipient self-administering the Tests and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from such self-administration.

In addition, I also hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Selected Retail Pharmacy Group and its officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “Selected Retail Pharmacy Group Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE SELECTED RETAIL PHARMACY GROUP RELEASEES OR OTHERWISE, THE TESTING RECIPIENT SELF-ADMINSTERING THE TESTS OR THE TESTING RECIPIENT’S PRESENCE ON SELECTED RETAIL PHARMACY GROUP’S PROPERTY TO OBTAIN THE TESTS. On behalf of the Testing Recipient, I hereby accept and assume all risks involved in the Testing Recipient self-administering the Tests and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from such self-administration.

In addition, by selecting “Accept” below, I certify that (i) this document has been completely explained to me; (ii) I read this document or someone read it to me; (iii) all of my questions regarding this document have been answered; and (iv) I completely understand this document, (v) I agree with all statements made in this document.