Healthcare Health Screening Agreement

HEALTH SCREENING AGREEMENT

Patient Information

Patient Name:    Date of Birth:

Male    Female    Other/Non-binary

Insurance Information

Medical History

Screening Details

Type of Screening (check all that apply):   Blood test   Urine test   Nasal/Throat swab   Vital signs (BP, temp, pulse)

Screening Date:    Screening Conducted By:

Risks, Benefits and Alternatives

I acknowledge that the health screening described above is intended to identify conditions that may require further evaluation or treatment. The benefits include early detection and facilitation of appropriate medical care. Risks are minimal but may include discomfort, fainting, bruising at the blood draw site, and the possibility of false positive or false negative results. Alternatives to the proposed screening include declining testing or seeking alternative tests. I have had the opportunity to ask questions and receive answers about the nature and purpose of the screening.

Consent and Authorization

By signing below, I authorize the healthcare provider and their agents to perform the screening procedures indicated above, to collect, process, and retain specimens, and to use and disclose screening results as described in this agreement. I authorize release of screening results to my primary care provider, to the individual(s) listed in the Emergency Contact field above if necessary for care, and to other healthcare entities as required for continuity of care. I understand that test results may be reported to public health authorities when required by law.

I understand that I may withdraw this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization. Withdrawal will not affect uses and disclosures made prior to receipt of the revocation.

This authorization will expire on: or upon completion of follow-up care as documented by the treating provider, whichever occurs first.

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 my rights with respect to that information. I understand that protected health information created or received in the course of the screening may be disclosed as permitted under applicable privacy laws and regulations.

I consent to the following communications regarding my screening and results:
By phone at the number on record    By text message    By email (if on file)

Emergency Authorization

In the event of an emergency arising from the screening procedure, I authorize the provider to provide or arrange for necessary emergency medical treatment. I understand that I will be responsible for charges incurred for such emergency care.

Attestation

I certify under penalty of perjury that the information I have provided on this form is true and correct to the best of my knowledge. I acknowledge that falsification of medical history or insurance information may affect my care and coverage.

If the patient is a minor or is unable to consent, a parent or legal guardian must sign below and indicate relationship to the patient.

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