COVID-19 Assessment

I acknowledge that NextGen Laboratories and its affiliates follow the HIPAA privacy rules regarding my treatment. I understand the content of the Notice of Privacy Practices and will be provided a copy upon request. I consent to general treatment medical procedures as prescribed by NextGen Laboratories and its affiliates. I acknowledge that telemedical interactions are solely given for the purpose of testing and managing possible COVID-19 exposure and testing; and that I will need a local medical provider to manage my health treatment, if needed, for COVID-19 or any other respiratory illness discovered. I understand that NextGen Laboratories' affiliate physicians and staff will not discuss my health information with my family and friends unless I expressly authorize them to do so. I acknowledge that the results of my testing from NextGen Laboratories, which will be screening me for COVID-19 and any other respiratory virus, will be reported to local public health officials and crisis response teams. I understand that if I do not answer, and also do not want a message left, NextGen Laboratories will try 3 more times to reach me. I understand that if I allow voicemails regarding my treatment, a message will be left with my results with no further attempt to contact me. I understand that I can call the listed number above to receive my results and ask any questions. I understand that NextGen Laboratories may send a letter containing no information related to specifics of my care or diagnosis, to my listed address requesting I contact them for my results if they cannot reach me on the phone. I consent to medical treatment and evaluation, care coordination, and procedures prescribed by NextGen Laboratories and its providers. 

By signing below, you understand NextGen Laboratories will bill your health insurance company directly. We may not be contracted with your health plan, however through the Cares Act all insurance companies are required to cover COVID-19 testing.

Do not sign unless you have read through this and had all questions answered. I authorize NextGen Laboratories and its providers to utilize telemedicine technologies in determining my diagnosis and treatment. I understand telemedicine means the practice of healthcare delivery, diagnosis, consultation, treatment, and transfer of medical data through interactive audio, video, or data communications that occurs in the physical presence of the patient. 

Benefits: Convenience, access healthcare when otherwise unable to seek it, need for expertise not otherwise accessible 

Risks: Audio or visual images may not be as good as in person. A telemedicine physician cannot use all of his/her senses and tools to assist in diagnosis or treatment. 

Alternatives: - Going to the ER-Seeking care at a physical location or outpatient/inpatient clinic for a consultation that may not produce a satisfactory outcome.

Confidentiality: I understand that every effort will be made to protect my health information security and confidentiality as part of telemedicine. 

Option not to participate: I have the option at any time to opt-out of this part of my NextGen Laboratories and its affiliate's plan.