Good Hearts Testing, LLC Consent and Release For HIV Testing

Good Hearts Testing, LLC

HIV Testing: Informed Consent and Release

Please carefully read and sign the following Informed Consent and Release:

• I authorize Good Hearts Testing, LLC to conduct collection and testing blood draw, as ordered by an authorized medical provider or public health official.
• I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be requested or required by law.
• I understand the risks associated with mobile laboratory testing which include but are not limited to bleeding, infection, and pain associated with the procedures required for specimen collection.
• I authorize Good Hearts Testing, LLC to provide my with a copy of my diagnostic testing results via HIPAA compliant email or telephone communication using the information provided in my booking. Furthermore I certify that I have verified the information provided in my booking and attest that m y contact has been reviewed and is correct.
• I understand the testing service is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
• I understand that, as with any medical test, there is the potential for a false positive or false negative results.
• If the purpose of my mobile diagnostic testing is for HIV testing:
  • The purpose of the test is to determine whether or not I have been infected with the Human Immunodeficiency Virus (HIV) and the meaning of the test results have also been explained to me.
  • I acknowledge that there has been made available to me information regarding measures for the prevention of, exposure to, and transmission of HIV. It has been explained to me that I will be informed of the positive test results and provided an opportunity for immediate face to face counseling in the event the results are positive.
  • I understand that the test results will become part of my medical record and Good Hearts Testing, LLC will assure that confidentiality safeguards are in place to limit disclosure. I authorize release of test results to those who are directly involved in my care or as permitted or required by law. In order that my hospital bill be paid, I authorize the release of my medical record containing my HIV test results to my insurance company or other third-party payor.
  • I understand anonymous testing is available in Dade County at various Department of Health sites. In accordance with Florida State law persons who test positive for HIV through the anonymous testing system will not be reported to the Department of health. By signing a limited waiver of anonymity, individuals who choose anonymous testing may receive services through the public health departments and other health providers without being reported. If persons who initially tested positive at an anonymous site are retested on or after July 1, 1997 outside the anonymous testing system, a positive result will be reported.
  • I have been given sufficient opportunity to discuss my condition and treatment with a representative of Good Hearts Testing, LLC and all my questions have been answered to my satisfaction. I believe that I have adequate knowledge upon which to base an informed consent. I understand that either my personal physician or a physician designated by Good Hearts Testing, LLC, has ordered my testing.
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• Refund Policy: By signing below I certify that I have read and agree to the refund policy outlined on Good Hearts Testing, LLC’s website (www.GoodHeartsHealth.com) under the FAQ section. Refunds will only be issued for canceled tests prior to specimen collection

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks of the procedure. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for diagnostic laboratory testing.

RELEASE OF LIABILITY AND WAIVER OF RIGHTS:

I, the undersigned, accept that services might be rendered in a non-private setting. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees Good Hearts Testing, LLC and their employees, owners and representatives from any and all claims, demands, actions and causes of action, which may result from participation in this testing.