Healthcare Test Kits

HEALTHCARE TEST KITS — PATIENT RECEIPT, CONSENT, AND AUTHORIZATION

Patient Information

Insurance & Billing

I acknowledge responsibility for payment as indicated below. Patient agrees that insurance may be billed for testing services and that any co-payments or non-covered amounts remain the patient's responsibility.

Billing responsibility: Patient    Insurance

Medical History

Test Kit Information & Chain of Custody

Kit ID:    Lot number:

Kit type (select all applicable):
COVID-19 Antigen   PCR (saliva/nasal)   STI Panel   Blood (fingerstick)

Specimen collected: Nasal swab   Saliva   Fingerstick blood

Sample collected by: Self    Healthcare worker/collector

Instructions, Handling & Storage

I confirm that I received verbal and written collection instructions appropriate to this kit. I understand that failure to follow instructions may invalidate the specimen and result in no reportable result.

Storage and expiration: This kit must be stored and used according to the included instructions. I acknowledge that the kit lot number and expiration are recorded above and that tests performed after the stated expiration may be invalid.

I confirm: I followed the instructions precisely and have sealed and labeled the specimen as required.

Authorization & Consent

By signing below, I authorize the performance of diagnostic testing on the submitted specimen and authorize the release of test results to my ordering clinician, named here: . I further authorize release of results to the following additional persons or organizations if applicable:

I understand that certain test results may be reportable to public health authorities as required by law and that information limited to what is legally required may be disclosed without additional consent.

I understand that I may withdraw this authorization at any time before specimen collection by notifying the collection site in writing. I further understand that if I withdraw authorization after specimen collection, the specimen may still be tested and results reported if required by law or necessary for clinical care.

Privacy & HIPAA Acknowledgment

By signing, I acknowledge receipt of the facility's privacy practices summary and understand how my protected health information related to this testing will be used and disclosed for treatment, payment, and healthcare operations consistent with applicable law.

Acknowledgment: I acknowledge receipt of privacy practices

Limitations, Liability & Disposal

I understand that no test is 100% sensitive or specific. False negatives and false positives may occur. The manufacturer and testing laboratory provide no express guarantee of clinical outcome. To the maximum extent permitted by law, I release and hold harmless the testing laboratory, kit manufacturer, distributor, and collection facility from liability for damages arising from improper collection after I accepted the kit or from limitations inherent in the test.

Disposal: I agree to dispose of kit components as directed; returned or mailed specimens must be packaged in the provided biohazard mailer and labeled as instructed.

Result Delivery & Contact Preferences

Preferred result notification method:
Phone call    SMS/Text    Email

Alternate contact number (if permission granted):

Expiration of Authorization

This authorization expires on: or upon completion of the testing and necessary reporting obligations, whichever occurs later.

Patient Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge receipt of the test kit, understand the instructions and limitations, authorize testing of the sample, and consent to the disclosure of results as stated above.

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