Fillable Port Of Entry Testing Form (City of Gustavus)

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Port Of Entry Testing Form (City of Gustavus)

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Page 1 of 2 Updated 7/6/2020 COMMUNITY TESTING DEMOGRAPHICS, RELEASE OF TESTING
INFORMATION, AND WAIVER OF CLAIMS FORM
COMMUNITY TESTING DEMOGRAPHICS, RELEASE OF
TESTING INFORMATION, AND WAIVER OF CLAIMS
TODAY’S DATE: ___________
Please Print
Legibly
Full Legal Name: _______ Gender: _____DOB:
First Middle Last
Home Mailing Address: ________________
Address City State Zip code
Phone #: E-mail Required:
Community Testing Location
Race
Ethnicity
Check Testing Location:
Juneau
Sitka
Wrangell
Haines
Klawock
Other: ___________
County: ____________
African American
White/Caucasian
American Indian/Alaska Native
Asian
Native Hawaiian or Pacific Islander
Other
Unknown by patient
Decline to answer
Hispanic, White
Hispanic, Black
Not Hispanic or Latino
Other
Unknown by patient
Decline to answer
First Covid-19 Test
Employed in Healthcare
(Female) Pregnant?
YES
YES
YES
NO
NO
NO
PURPOSE AND BACKGROUND. The Southeast Alaska Regional Health Consortium (“SEARHC”) is testing Patient
to determine if Patient is currently infected with the COVID-19 virus, pursuant to the SEARHC community-wide COVID-19
testing program, which is voluntary. SEARHC is a tribal health organization that provides comprehensive health services
throughout Southeast Alaska, under the Alaska Tribal Health Compact and Funding Agreements with the U.S. Secretary of
Health and Human Services as authorized by Title V of the Indian Self-Determination and Education Act of 1975, as
amended, 25 U.S.C. §§ 5301-5423.
RELEASE OF RESULTS. Patient understands that SEARHC is required by law to report positive test results directly
to the State of Alaska for the purposes of COVID-19 infection prevention and response. Patient also understands that this
information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and SEARHC will use
or disclose the information only as permitted by HIPAA and described in its Notice of Privacy Practices. Patient
understands that the information may no longer be protected by HIPAA once disclosed to the State of Alaska, and SEARHC
has no control over the State of Alaska’s use or disclosure of results.
TESTING TYPE. Patient will do a NASAL SELF-SWAB PCR TEST. Patient understands and agrees that SEARHC has
the absolute discretion to choose the brand and type of test(s) used based on available supplies, patient and workforce
demands, as well as any guidance currently in effect issued by the Food and Drug Administration or Centers for Disease
Control and Prevention. SEARHC may interpret the test samples in-house or send the samples to outside labs for
GUSTAVUS
✔
GUSTAVUS POINT OF ENTRY
Page 2 of 2 Updated 6/6/2020 COMMUNITY TESTING DEMOGRAPHICS, RELEASE OF TESTING INFORMATION, AND WAIVER OF CLAIMS FORM
interpretation. Patient may request details about the type of testing used by SEARHC. Patient understands that test results
may not be made available immediately after the test is performed, and may take several days or longer to arrive,
depending on the availability of test analysis facilities, equipment, and supplies.
METHOD OF NOTIFICATION. SEARHC will notify Patient of the test results by encrypted e-mail or the Patient may
arrange to pick up the results by calling the number listed above. Patient acknowledges and understands that SEARHC
does not control or have responsibility for the security of Patient’s chosen e-mail account in order to prevent unauthorized
access to Patient’s e-mail.
RISKS. Patient understands that testing for the COVID-19 virus and interpretation of the test results is not perfect,
and false positives or false negatives are possible. Patient further understands that nasal testing for COVID-19 may cause
gagging, coughing, discomfort, or minor nosebleeds.
WAIVER OF CLAIMS. SEARHC is not responsible for the State of Alaska’s actions or decisions regarding COVID-19
infection response and prevention, including any actions in response to a positive COVID-19 test result, including if the
result is a false positive. Patient agrees and understands that it is patient’s responsibility to protect others from infection
pending and after receipt of the test results. SEARHC is not responsible for the consequences of a false negative result,
such as the unintentional infection of other individuals, and any resultant illness, injury or death. Patient voluntarily and
on behalf of Patient and Patient’s heirs and assigns, hereby releases and forever discharges SEARHC, its officers, directors,
trustees, board members, providers employees, agents, attorneys and assigns from all claims, demands, actions and
causes of action whatsoever, of any sort, whether known or unknown, arising now, in the future, from or relating to in
any manner whatsoever, SEARHC’s testing of Patient pursuant to this consent to testing, including SEARHC’s negligence
and any injury, illness or death resulting from the testing or from SEARHC’s negligence in administering the testing or
directing Patient during the self-swab, or SEARHC’s disclosure of the test results to the State of Alaska as otherwise
required by law.
BY SIGNING THIS AGREEMENT I AM REPRESENTING THAT I HAVE READ AND UNDERSTOOD THIS RELEASE OF TEST
RESULTS AND WAIVER OF CLAIMS AND I AGREE TO BE BOUND BY ITS TERMS AND ASSUME ALL RISKS INHERENT IN OR
ARISING FROM TESTING FOR COVID-19.
Patient (or Parent/Guardian on Minor’s Behalf) Signature
DATED __________________, 2020.
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Port Of Entry Testing Form (City of Gustavus)

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Completed 23 January 2021

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