Healthcare Screening Consent Form

HEALTHCARE SCREENING CONSENT FORM

This Healthcare Screening Consent Form documents informed consent to undergo one or more screening tests and authorizes release and use of screening results as described below. The patient named below has been provided with an explanation of the screening procedures, associated risks and benefits, reasonable alternatives, and has had the opportunity to ask questions. By signing this form the patient (or authorized representative) voluntarily consents to the screening services set forth herein.

Patient Information

Male Female Other Decline to State

Insurance Information

Medical History

Is the patient pregnant or breastfeeding? Yes No Unknown

Screening Details and Authorization

I authorize the following screening procedures to be performed as indicated by the provider:

COVID-19 testing (swab/antigen/PCR) Tuberculosis screening (PPD or IGRA) Blood tests (e.g. CBC, metabolic panel) Urine analysis Vision screening Hearing screening Other:

Risks, Benefits, and Alternatives

The patient has been informed of the purpose of the screening test(s), expected benefits, and reasonably foreseeable risks, which may include discomfort, bruising, bleeding, infection at the collection site, false positive or false negative results, and need for additional testing. The patient understands that not undergoing screening may delay diagnosis or treatment. Reasonable alternatives, including forgoing the test, were explained and discussed.

Voluntary Participation and Right to Withdraw

Participation in this screening is voluntary. The patient may refuse or withdraw consent at any time prior to performance of the test without penalty or loss of access to other care. Withdrawal of consent will not affect treatment previously provided.

Confidentiality, Release of Results, and Authorization

The results of screening tests are protected health information. By signing below, the patient authorizes the release of screening results to the following individuals or entities (if left blank, release will be limited to the patient and treating providers):

I consent to results being communicated by: Phone Email Mail

The patient authorizes retention and, where applicable, limited use of residual specimens for quality assurance or public health reporting as required by law, unless the patient checks the box below to refuse such retention.

I refuse retention/use of residual specimens beyond those required for testing and reporting.

HIPAA Acknowledgment

By initialing or checking below, the patient acknowledges receipt of the facility's privacy practices and understands how health information related to the screening will be used and disclosed for treatment, payment, and healthcare operations as permitted by law.

I acknowledge receipt of the Privacy Practices and understand how screening results may be used and disclosed.

Additional Disclosures

Certain communicable disease results may be reported to public health authorities as required by law. Test results may require confirmation by additional testing. The provider has explained to the patient any material limitations or conditions that could affect test performance and interpretation.

Certification and Signature

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have read (or had read to me) the information on this form, all my questions have been answered, and I voluntarily consent to the screening services indicated. If signing as an authorized representative, I certify that I am authorized to sign on the patient's behalf and that documentation of this authority is on file or accompanying this form.

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