Healthcare COVID-19 Waiver

HEALTHCARE COVID-19 WAIVER

Facility Name:    Location/Department:

Patient Information

Insurance Information

Medical History

COVID-19 Screening & Vaccination

In the past 14 days, have you experienced any of the following? Check all that apply:

Vaccination status (select all that apply):

Acknowledgment, Assumption of Risk, and Release

I, the undersigned Patient, acknowledge that COVID-19 is a contagious disease that can result in serious illness or death. I voluntarily seek services at the facility named above and understand that receiving care may expose me to the risk of contracting COVID-19 despite the facility's infection control efforts.

Assumption of Risk: I knowingly and freely assume all such risks related to exposure to COVID-19 in connection with my presence at the facility and participation in care or services. I accept full responsibility for personal injury, illness, permanent disability, or death.

Release and Waiver: To the fullest extent permitted by law, I hereby release, waive, discharge, and covenant not to sue the facility, its directors, officers, employees, contractors, volunteers, and agents from any and all claims, demands, liabilities, damages, or causes of action, whether known or unknown, arising out of or relating to exposure to COVID-19 associated with my receipt of services. This release includes claims arising from the negligence of the released parties.

Indemnification: I agree to indemnify, defend, and hold harmless the facility and its representatives against any third-party claims, liabilities, or expenses (including reasonable legal fees) arising from my negligent acts or omissions related to COVID-19 exposure while on facility premises or during facility-provided services.

Consent to Screening, Testing, and Protocols

I consent to any screening procedures required by the facility, including symptom screening, temperature checks, and COVID-19 testing when clinically or administratively indicated. I agree to follow facility infection prevention protocols, which may include masking, physical distancing, and restrictions on visitors. I understand that refusal to comply may result in delayed or denied services.

Testing Authorization: I authorize the facility to collect specimens for COVID-19 testing and to perform such tests. I authorize the facility to release test results to my healthcare providers as necessary for my care and to public health authorities as required by law.

HIPAA / Privacy Acknowledgment

I acknowledge that the facility has provided or made available its Notice of Privacy Practices. I understand that protected health information related to COVID-19 testing and treatment may be used and disclosed for treatment, payment, and healthcare operations as described in that notice and as required by law.

Authorization and Expiration

This authorization and release shall remain in effect for the duration of the public health emergency related to COVID-19 unless sooner revoked in writing. If a specific expiration date is required, enter below:

Patient Attestation

By signing below, I certify under penalty of perjury that I have read and understand this COVID-19 Waiver, that the information I have provided on this form is true and complete to the best of my knowledge, and that I am authorized to execute this document. I understand I may withdraw this authorization at any time by providing written notice to the facility, but withdrawal will not affect actions taken in reliance on this authorization prior to receipt of my revocation.

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