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I "Pitt (Ol,LQ.. ty_ --------= D r.Joh n (County Of Pitt)

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File type: PDF

U.S.A. forms for County Of Pitt

BROWSE COUNTY OF PITT (NC) FORMS

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"Pitt
(Ol,LQ..
ty_
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r.Joh
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_ GEN141-E
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General Consent
For
Services
I hereby acknowledge that I have received a copy
of
the uNotice
of
Privacy Practices"
for
Pitt
County Health Department and have been informed that I
may
contact the person named
therein if
I have questions about the content
of
the notice.
I hereby voluntarily consent to medical examinations, treatments and procedures which are
deemed necessary
by
the physician
or
other health care provider
at
the health department,
including immunizations,
TB
skin test, HIV tests and other laboratory tests.
I have been informed that
my
medical information is confidential and is protected
by
NC law
130A-12.
I have been informed that if any problems are identified, recommendations will be made
to
me
concerning appropriate follow-up and it is
my
responsibility
to
follow through with these
recommendations.
I will notify the Health Department
of
any
changes in
my
address and/or
telept)one number so that I may be notified promptly
if
necessary.
My
signature on this page indicates that I have been given the opportunity to have all
my
questions answered and have also been given the opportunity to refuse services. I understand
that this consent is
valid until I revoke it and that if I want
to
revoke this consent I must do
so
in
· writing.
I authorize the Health Department to submit claims to
my
insurance company on
my
behalf and
in my name for
any
services
ren~ered
with the undersfanding that any benefit payments will be
assigned directly to the
Pitt County Health Department. I also authorize the
rele~se
of
any
medical information needed to process any claim.
··
··
________
___.:
!
__
-------------~
'---
Client
Signature
Date
Witness
Signature
Date
--------~
'----
Interpreter
Signature
Date
I
authorize
Pitt
County
Health
Department
to
contact
me
through
electronic
means,
text
messaging
and/or
voicemail,
for
appointment
reminders
at
the
tele
phone
numbers
I
have
previously
provided
.
..___
__
____,!
I
authorize
Pitt
County
Health
Department
to
use
my
photograph
to
identify
me
and
assist
in
my
care.
This
information
will
not
be
released
for
any
other
purpose
without
my
expressed
written
permission.
111Y1Hd
1C113011B
www.pittcountync.gov
201
Government Orcle Pitt County Office
Park
Greenville,
N.C.
27834 252.902.2305 fax: 252.413.1446
MAKE:
MODEL:
COLOR:
click to sign
signature
click to edit
Statement of Permission for COVID-19 Testing
Name: ____________________________________________________________________________________________
Last First Middle
Gender: (circle) Male Female Date of Birth: ___________ Social Security Number: __________________
Address: __________________________________________________________________________________________
City: ______________________________________ State: _______ Zip code: ________________________
County of residence__________________________
Best contact phone number #: ________________________ Work Mobile home
Email address___________________________ Preferred Language: (circle) English Spanish Other
Ethnicity: (circle) African-American Caucasian Latino Other___________________
Race: (circle) Black/ Non-Hispanic Hispanic Non-Hispanic White Asian/Pacific Islander
Native-American Other___________________
Signed Patient Consent
By Signing Below: I hereby acknowledge that I have read and agree to follow the guidance in NC DHHS Steps
for People After COVDI-19 Testing. __________ (Please Initial)
Notice of Privacy Practices
By Signing Below: I hereby acknowledge a copy of the “Notice of Privacy Practices” for the Pitt County Health
Department was available for me to read and/or receive a copy. __________ (Please Initial)
Medical Record Release
By Signing Below: I authorize Pitt County Health Department to disclose COVID testing results to me, the
patient, for personal use. I understand that I can access my results via MyChart. The Pitt County Health
Department will contact me if the COVID-19 test result is positive. __________ (Please Initial)
Signature: ________________________________________________ Date: _____________________
click to sign
signature
click to edit
COVID-19 Questionnaire
What is your Primary Care Provider’s name: ________________________________________________________
Are you having COVID-19
symptoms?
(Chest pain, shortness of breath, cough, fever/chills, headache, no taste/smell,
nausea/vomiting, diarrhea, fatigue/aches, sore throat)
Yes No Date of symptom onset_______________________
Have you been hospitalized for
COVID-19?
Yes
No Were you treated in an intensive care unit?
Yes
No
Is this your first COVID-19 test
Yes
No
Do you work in healthcare?
Are you pregnant?
Yes
No
Do you live in
Nursing home?
Yes
No
Group home?
Yes
No
Board and care home?
Yes
No
Homeless shelter?
Yes
No
Foster Care?
Yes
No
Residential setting for people with intellectual or developmental disabilities?
Yes No
Psychiatric treatment facility?
Yes
No
FOR HEALTH DEPARTMENT USE ONLY
87635 (COVID Test) Date sample collected: _________________
Specimen type: NP OP Nasal
Specimen sent to: NCSLPH LabCorp Vidant
Dx Code Z11.59
Specimen obtained by: _____________________________________
(print first name last name and discipline)
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I Pitt (Ol,LQ.. ty_ --------= D r.Joh n (County Of Pitt)

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Completed 22 January 2021

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