I voluntarily consent to and authorize Pala Diagnostics, LLC (“Pala”) and its authorized representatives to conduct 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 Federal regulations or by the rules and policies of my workplace or the sponsor of the event which I am attending. Pala does not have any control over 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 Pala nor its representatives are capable of providing medical advice.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Pala and its representatives, including, without limitation, any 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, and fail to provide valid insurance information and/or a valid Photo ID that Pala may not be able to verify may identity. Not providing valid identifying information may run the risk of me receiving a bill for testing services.
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 anytime 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 opt 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 Pala 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 Pala. 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 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 Pala 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 Pala 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 that my failure to disclose knowledge of a positive COVID-19 test result to Pala, 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 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.
Pala Diagnostics, LLC, 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). Pala is committed to continuous improvement to ensure its services incorporate the latest in information technology privacy and security measures.
Administrative Safeguards (HIPAA 164.308). Pala 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 annual review of policy effectiveness during internal or 3rd party auditing of our services.
Physical Safeguards (HIPAA 164.310). Pala’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. Pala’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, Pala 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.
Current as of September 1, 2021 Revision 2