I voluntarily consent to and authorize the laboratory conducting this testing (“The Lab”) and its authorized representatives to conduct the collection, testing, and analysis for the purposes of a COVID-19 diagnostic and/or screening test. I acknowledge and understand that my COVID-19 diagnostic and/or screening test will require the collection of an appropriate sample by a healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection method.
I understand that this testing may be mandated by State or Federal regulations or by the rules and policies of my workplace or the sponsor of the event which I am attending. The Lab does not have any control over State or Federal regulations, or the rules and policies of privately sponsored testing.
Authorization and Consent for COVID-19 Testing
I understand there are risks associated with undergoing a diagnostic and/or screening test for COVID-19 and there may be a potential for false-positive or false-negative test results. I understand and take full and complete responsibility for any self-reporting and/or quarantining actions needed in regard to my test results. I understand that I must seek medical advice and/or treatment from my own healthcare provider and that The Lab nor its representatives are capable of providing medical advice.
To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, The Lab and its representatives, including, without limitation, any of its respective members, officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.
I understand that if I fail to provide my Social Security Number or Taxpayer Identification Number, when requested, and fail to provide valid insurance information and/or a valid Photo ID that The Lab may not be able to verify my identity. Not providing valid identifying information may run the risk of me receiving a bill for testing services if my provider rejects the claim.
Authorization and Consent to Receive Results via Text Message and/or Electronic Mail
I consent to the receipt of my results via secure e-mail or via secure text message and understand that I must provide a valid e-mail address and/or telephone number along with valid birthdate in order to receive my results. I understand it is my responsibility to provide correct contact information and that the failure to do so may result in my inability to receive my results. Message and data rates may apply.
Opt-Out Policy for Text Message and/or Electronic Mail
I understand that the only way to receive my results is via text message and electronic mail. If at any time I wish to stop receiving results via text message and/or electronic mail, I understand I must notify LabPort via email at [email protected] Upon opting out I understand I will no longer have the ability to receive my results via text message and/or electronic mail.
Authorization and Consent for Billing
If I have selected that I do not have health insurance, by signing and submitting this registration I am confirming that I do not have health insurance coverage through any provider and have provided a valid social security number and valid photo ID. I authorize The Lab and/or or their assignee or designee to receive payments for this test on my behalf from my health insurance provider or other reimbursement from State or Federal programs made available for COVID-19 testing. I understand that with this assignment of benefit, I am responsible for any payments due if my insurer does not cover this test due to lapsed coverage. If my insurer sends the reimbursement to me directly, I am responsible for ensuring payment to The Lab. I authorize the release of necessary information that may be protected health information to the party processing the claim and authorize their action as my power of attorney for request of appeal and documents. I understand that an Explanation of Benefits is not a bill, and that in the unlikely event The Lab bills me directly, it will be clearly marked as an invoice.
I understand that this section is not applicable if I have voluntarily chosen to pay directly for this COVID-19 testing.
Authorization and Consent for Release of Results
I consent to the release of my COVID-19 test results to the Sponsor (as used herein, the “Sponsor” is the party who has engaged The Lab to conduct this testing) of this testing and to any parties required to receive the results of my COVID-19 test result either by law or by policy, including but limited to the hotel, event center, or physical premises at which I am conducting the testing. I acknowledge and agree that The Lab may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be required by law.
I understand that my employer or the site sponsoring this testing may require results in order for me to participate, attend, or otherwise be a part of an event or continue my stay on the physical premises. I understand that my information will be kept in the strictest confidentiality, and only the minimum information necessary to identify my result will be released, which may include my name and contact information, along with my result.
IN THE EVENT OF A POSITIVE RESULT, I understand that it may not be possible to contact me before the release of a positive result and authorize the release of my positive result according to the guidelines set forth by the event organizer and/or the operator of the physical premises on which the event is conducted. I understand my failure to disclose knowledge of a positive COVID-19 test result to The Lab, the event sponsor, or the operator of the physical premises, as may be required by law or the policies set forth by any of the aforementioned parties, is a liability of my own. I am responsible for self-reporting any positive results that I have received.
By signing and submitting my registration for COVID-19 testing, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form and that the information herein is true and correct. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic and/or screening test, I may decline to receive continued services.
Labport, its officers, directors, employees, and associated companies are committed to and have implemented many safeguards to ensure its devices, services, websites and data systems are compliant with the regulations and conditions set forth in the Health Insurance Portability and Availability Act of 1996 (HIPAA). Labport is committed to continuous improvement to ensure its services incorporate the latest in information technology privacy and security measures.
Administrative Safeguards (HIPAA 164.308). Labport has implemented policies to ensure appropriate assignment of data access permissions and proper movement and handling of that data. HIPAA training is an annual mandated event for all staff, as well as an annual review of policy effectiveness during internal or 3rd party auditing of our services.
Physical Safeguards (HIPAA 164.310). Labport’s primary physical safeguard is to not retain sensitive data in any public or private location other than those assigned for database management and quality assurance activities. Specific workstation usage, disposal, reuse and security measures are in place. Access to all facilities are independently controlled via card access preventing walk-up intrusion. Labport’s data center uses a cloud based architecture with inherent security measures including 24 hours monitoring, advanced fire protection systems, uninterruptible power and database redundancy. Annual audit of the facility security plan, disaster recovery plan, and contingency plans are in place. All physical access to data is restricted via encrypted hardware.
Technical Safeguards (HIPAA 164.312). To further protect sensitive data, Labport enforces unique software architecture that includes user identifications, various database audit logging, data integrity systems and verified backups, entity authentication programs, digital certificates, various levels of encryption and other custom architecture to further obscure sensitive data. Your data is never shared with third parties without your authorization.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Under federal law, if you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post stabilization services.
California law also protects enrollees in state-regulated plans from surprise medical bills when an enrollee receives emergency services from a doctor or hospital that is not contracted with the patient’s health plan or medical group. If you are a covered enrollee, providers cannot bill you more than their in-network cost-sharing.
Certain services at an in-network hospital or ambulatory surgical center Under federal law, when you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
California law also protects enrollees in state-regulated plans from surprise medical bills when an enrollee receives care at an in-network facility such as a hospital, lab, or imaging center, but services are delivered by an out-of-network provider. If you are a covered enrollee, providers cannot bill you more than their in-network cost-sharing without your consent. If your plan includes coverage for out-of-network benefits, you may only be billed for the out-of-network cost-sharing under California law if you consent in writing at least 24 hours in advance of care and receive a written estimate of the total out-of-pocket cost of care.
When balance billing isn’t allowed, you also have the following:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact 1-888-466-2219 for enforcement issues related to state-regulated plans or 1-800-985-3059
(https://www.cms.gov/nosurprises/consumers) for enforcement issues related to federally regulated plans.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.
Visit www.HealthHelp.ca.gov for more information about your rights under state law.