Healthcare COVID Patient Consent Form

HEALTHCARE COVID PATIENT CONSENT FORM

Patient Information

Insurance Information

Medical History

COVID-19 Screening

Has the patient experienced any of the following symptoms in the past 14 days? (check all that apply)

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
New loss of taste or smell
Sore throat

Known exposure to a confirmed COVID-19 case within past 14 days: Yes No

Prior positive COVID-19 test: Yes No

COVID-19 vaccination status (check all that apply):

Not vaccinated
Partially vaccinated
Fully vaccinated
Received booster

Is the patient pregnant or breastfeeding? Yes No

Does the patient have a condition that weakens the immune system? Yes No

Consent for COVID-19 Testing, Specimen Collection and Treatment

I, the undersigned, authorize the healthcare facility and its authorized personnel to perform COVID-19 diagnostic testing, to collect specimens (including but not limited to nasal swab, nasopharyngeal swab, saliva), and to perform or arrange ancillary clinical evaluation and treatment as medically indicated. I understand that testing and specimen collection may cause brief discomfort and that no procedure is entirely without risk.

I consent to (check each that applies):

Diagnostic testing for SARS-CoV-2 (COVID-19)
Specimen collection (e.g., nasal or saliva swab)
Administration of clinically indicated treatment related to COVID-19 (as ordered by treating clinician)
Telehealth consultation and electronic communication necessary for my care

I understand that I may decline testing or treatment and that refusal will be documented in the medical record. I acknowledge that refusing testing or treatment may limit the ability of clinicians to provide specific care and public health actions.

Risks, Benefits and Alternatives

The benefits of testing and appropriate treatment include detection of infection, initiation of monitoring or therapy when indicated, and reduction of transmission risk to others. Risks may include discomfort at the specimen collection site, false negative or false positive test results, allergic reaction to therapeutics, and rare adverse events associated with treatments. Alternatives include declining testing, which may reduce interventions available to you or delay diagnosis.

I have had the opportunity to ask questions about the procedure(s), risks, benefits and alternatives, and my questions have been answered to my satisfaction.

Authorization to Disclose and Receive Information

I authorize disclosure of my COVID-19 test results and related health information to those listed below and to public health authorities as required by law. I understand that test results may be reported for public health surveillance and contact tracing.

Release results to household members
Release results to employer or school (if authorized)
Release results to insurance carrier for billing
Release results to other recipient (specify below)

HIPAA and Privacy Acknowledgment

I acknowledge that I have received or been offered the facility's Notice of Privacy Practices describing how my health information may be used and disclosed, and that information about my COVID-19 test and results may be shared as necessary for treatment, payment, and public health purposes.

I acknowledge receipt of the Privacy Notice and consent to use and disclosure as described above.

Authorization Duration and Revocation

This authorization to disclose information and to perform diagnostic testing and related treatment will remain in effect until the following date or until revoked in writing, whichever occurs first.

I understand that I may revoke this authorization at any time by providing written notice to the facility, except to the extent that action has already been taken in reliance on this authorization.

Additional Notes

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