HM AT&T #221035 Rapid Antigen Testing

Rapid Antigen Testing
Please complete this form for production to properly complete your test.
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
First NameLast Name
Email
example@example.com
Job title or position on set
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Area CodePhone Number
Above listed patient authorizes the following healthcare facility to make record disclosure for the single date above only Facility Name: Access Bio, Inc. MedicalGroup (661) 992-0517
The purpose of disclosure is:
Other: Rapid Antigen, Analyzer Antigen, Antibody (IGG/IGM), and PCR Test Results
RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.
l understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
Patient Signature
Clear
Informed Consent for Specimen Collection
I hereby consent to the drawing of a specimen collection for the purpose of diagnosis and/or medical treatment. I understand that the risks involved with specimen collections include, but are not limited to, discomfort at the site of collection. I understand and accept that data derived from this specimen collection is considered preliminary only and does not constitute any kind of diagnosis. It is my responsibility to initiate a follow-up examination to confirm results and obtain professional advice and medical treatment. SetMedicLA (Cody Vlach Medical License#P31150, Gloria Koehler H&SM) will keep my results confidential and will only release information to other organizations with my consent.
Performed by: Cody Vlach, Medical Advisor #P31150
Authorized by: T. Sloane, MD Medical Director
Results
Testing Results
Number:
Initials:
Should be Empty:

Results