Helix Consent To COVID-19 Diagnostic Testing
Last Modified: June 18, 2020
YOU AGREE TO RECEIVE THE FOLLOWING SERVICES PROVIDED BY HELIX:
COLLECTION OF A SWAB SPECIMEN
TESTING OF YOUR SPECIMEN TO DETERMINE IF THE SARS-COV-2 VIRUS THAT CAUSES COVID-19 IS PRESENT
RETURN OF TEST RESULTS TO YOU AND YOUR EMPLOYER
HELIX HAS ENGAGED AN INDEPENDENT PHYSICIAN TO OVERSEE COVID-19 DIAGNOSTIC TESTING. THIS PHYSICIAN IS REFERRED TO IN THIS CONSENT AS “MJB LAB SERVICES.” YOU AGREE TO RECEIVE THE FOLLOWING SERVICES PROVIDED BY MJB LAB SERVICES:
REVIEW OF YOUR TEST REQUEST
DETERMINATION OF WHETHER OR NOT A TEST IS APPROPRIATE FOR YOU
REVIEW OF YOUR TEST RESULTS
YOU UNDERSTAND AND SPECIFICALLY AUTHORIZE HELIX TO TRANSFER AND RELEASE THE INFORMATION YOU PROVIDE TO HELIX TO MJB LAB SERVICES FOR THE SOLE PURPOSE OF PROVIDING YOU WITH THE COVID-19 DIAGNOSTIC TESTING SERVICES DESCRIBED IN THIS CONSENT.
NEITHER HELIX NOR MJB LAB SERVICES WILL PROVIDE ANY SERVICES BEYOND THOSE EXPLICITLY DESCRIBED IN THIS CONSENT FORM. AMONG OTHER THINGS, THIS MEANS THAT NEITHER HELIX NOR MJB LAB SERVICES WILL PROVIDE YOU WITH FOLLOW-UP CARE, COORDINATION OF IMMEDIATE OR FUTURE CARE, OR CLINICAL CARE SERVICES. TESTING IS NOT TREATMENT AND YOU SHOULD NOT WAIT FOR TEST RESULTS TO CONTACT YOUR HEALTHCARE PROVIDER AND SEEK TREATMENT IF YOUR SYMPTOMS WORSEN OR YOU EXPERIENCE AN ONSET OF NEW SYMPTOMS. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR HEALTHCARE PROVIDER OR 911 IMMEDIATELY. NEITHER HELIX NOR MJB LAB SERVICES ARE EMERGENCY CARE PROVIDERS.
BY SIGNING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DECLINE TO SIGN THIS CONSENT, YOU WILL NOT BE ABLE TO USE THE SERVICES.
I understand that MJB Lab Services, Inc. (“MJB Lab Services”) is responsible for physician oversight of the COVID-19 diagnostic testing service I am seeking (“Test”), including review of Test requests, ordering of a Test if I meet testing requirements, and review of Test results. Helix is responsible for laboratory testing services only. I acknowledge that neither MJB Lab Services nor Helix will provide consultation services or clinical care outside the limited scope of the Test. If my Test result is positive, I agree that I will follow up directly with my primary care physician or healthcare provider.
I acknowledge and agree to the following:
I consent to diagnostic testing for the SARS-CoV-2 virus that causes COVID-19.
I am at least eighteen (18) years old.
My employer provided me with an “Authorization to Disclose Medical Information” form allowing Helix to provide my Test results to my employer, and I signed this authorization.
The information I have provided to Helix and MJB Lab Services is correct. Neither Helix nor MJB Lab Services will be responsible for errors or omissions that occur as a result of me providing them with incorrect or incomplete information. I understand that MJB Lab Services will determine if diagnostic testing is appropriate for me and will review my Test results using secure electronic communications. I specifically authorize Helix to transfer and release my information to MJB Lab Services to determine if a Test is appropriate for me and review Test results.
I am responsible for following up with my primary care physician or healthcare provider if I have questions regarding my Test results. I am responsible for forwarding my Test results to my primary care physician or healthcare provider if I seek follow-up consultation or care.
The diagnostic testing service I will receive does not constitute treatment of any condition, illness, or disease.
While Helix adheres to rigorous laboratory quality standards, I understand that laboratory tests sometimes produce a false positive or false negative result.
I am responsible for checking my email for Test results.
I understand that testing is voluntary. I may withdraw my consent to testing at any time prior to completion of the Test by notifying my employer that I no longer consent to testing.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS AND CONSENT FULLY AND VOLUNTARILY TO ITS CONTENTS. THIS CONSENT TO DIAGNOSTIC TESTING WILL EXPIRE ON DECEMBER 31, 2025 UNLESS REVOKED. CONSENT MAY BE REVOKED BY SENDING WRITTEN NOTICE TO HELIX’S PRIVACY OFFICER: PRIVACYOFFICER@HELIX.COM. THE REVOCATION WILL TAKE EFFECT WHEN HELIX RECEIVES IT, EXCEPT TO THE EXTENT HELIX OR OTHERS HAVE ALREADY RELIED ON THIS AUTHORIZATION.