DHMD COVID-19 Testing
Terms and Conditions

The purpose of this Acknowledgement and Consent Agreement (“Agreement”) is to provide and acquire information, set forth the terms and conditions of services, and obtain Participant’s consent for Provider to collect a respiratory specimen by way of a nasopharyngeal or nasal swab and either (1) analyze it using the ABBOTT ID NOWTM COVID-19 test, BD VeritorTM System for Rapid Detection of SARS-CoV-2 – BD, or Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV test (hereinafter individually, or collectively, “Rapid Test”) for the presence of the SARS-CoV-2 virus or (2) deliver it to the University of Washington, Atlas Genomics, and/or Worksite Labs (“Lab”) to analyze it using the Thermo Fisher Scientific TaqPathTM Combo Kit, UW SARS-CoV-2 Real-time RT-PCR assay, cobas® SARS-CoV-2 Real-time RT-PCR Diagnostic Panel, or Panther Fusion® SARS-CoV-2 assay (hereinafter individually, or collectively, “Lab PCR Test”) for the presence of the SARS-CoV-2 virus.

  1. Participant Disclosures:
    1. I state and affirm that I am not experiencing any of the following symptoms:
      • Chills, cough, fever (temperatures above 100.4°F), shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea.
    2. I ATTEST AND WARRANT THAT THE STATEMENT ABOVE IS TRUTHFUL.
    3. I ATTEST AND WARRANT THAT, REGARDLESS OF MY TEST RESULT(S), I WILL NOT BOARD OR TRAVEL ON AN AIRPLANE IF I HAVE ANY OF THE ABOVE LISTED COVID-19 SYMPTOMS.
    4. I ATTEST AND WARRANT THAT, REGARDLESS OF MY TEST RESULTS, THAT I WILL NOT BOARD OR TRAVEL ON AN AIRPLANE IF I HAVE HAD CLOSE CONTACT WITH, OR RESIDED WITH, ANYONE THAT HAS HAD A POSITIVE COVID-19 TEST WITHIN THE PRIOR FOURTEEN (14) DAYS.
  2. Informed Consent:
    1. I have reviewed and read the following relevant Fact Sheets of Patients:
    2. I understand that my participation in the Rapid Test and/or Lab PCR Test is entirely voluntary. I understand that the FDA has allowed the use of the Rapid Test and the Lab PCR Test even though it has not been formally approved. The Rapid Test and the Lab PCR Test are available under an emergency access mechanism called an Emergency Use Authorization (EUA).
  3. I authorize Provider to collect a respiratory specimen through a nasal swab and to analyze the specimen collected with the Rapid Test and/or to collect a respiratory specimen through a nasal swab, to package the specimen acquired, and to transport and deliver the specimen to the Lab for analysis using a Lab PCR Test.
  4. I understand that I am not creating a patient relationship with the Provider, or ordering physician, by way of this Agreement or by participating in this testing. I understand that the Provider is not acting as, and is not, my medical provider or my health care provider, and that testing does not replace treatment by my medical provider.  I understand that the Provider does not offer medical advice.    I assume complete and full responsibility to take appropriate action with regards to my test results and my medical care.  I agree that I will seek medical advice, care, and treatment from my medical provider or other health care entity if I have questions or concerns or if I develop symptoms of COVID-19 or if my condition worsens.  I agree and understand that I am solely responsible for seeking, and paying for, any medical care, medical treatment, or other costs and expenses, that I might need or incur in response to the result received from the Rapid Test and/or Lab PCR Test. I assume complete and full responsibility to take appropriate action in response and regard to my test results. I understand that it is my responsibility to inform my health care provider of my Rapid Test and/or Lab PCR Test result.
  5. I understand that Provider will provide my Rapid Test result directly to me. I understand that at the time a specimen is acquired from me for testing, I will receive a QR code.  I will access my Lab PCR Test result(s) online at https://securelink.labmed.uw.edu/ or atlas-genomics.com.
  6. I understand that Provider will not provide my Rapid Test and/or Lab PCR Test result(s) to my health care provider or to any airline.
  7. I acknowledge and agree that Provider may disclose my Rapid Test and/or Lab PCR Test result(s) and the information provided on this Agreement to: (i) federal and state agencies and public health authorities.; (ii)  the employer I identified on this Agreement; (iii) and to any entity or agency that paid Provider for the services rendered under this Agreement.
  8. I acknowledge and understand that a positive Rapid Test and/or Lab PCR Test result indicates that I am not fit to travel and that I shall thereafter immediately isolate for at least ten (10) days.
  9. I acknowledge and understand and agree that if I receive a positive Rapid test and/or Lab PCR Test result that I will immediately notify any individuals that I reside with or who are on my travel itinerary of my positive result.
  10. I acknowledge and understand that a negative Rapid Test and/or Lab PCR Test result is not a guarantee that I am not currently infected with COVID-19.
  11. I acknowledge and understand that if I receive a negative Rapid Test and/or Lab PCR Test result, but yet have symptoms of COVID-19, that I may have an active COVID-19 infection and am not fit to travel.
  12. I acknowledge and understand that if I am not quarantined or isolated while ill with COVID-19, that I could pose a substantial and direct threat to my own safety as well as the health and safety of other persons. I acknowledge and understand that if I travel on an airplane while ill with COVID-19, I will pose a direct threat to everyone I come into contact during the course of that travel.
  13. I acknowledge and understand that Provider is under no obligation to provide further, repeat, or confirming testing of my Rapid Test and/or Lab PCR Test result.
  14. I recognize that there are certain inherent risks associated with having a respiratory specimen collected and analyzed. I understand that there are risks and benefits associated with Rapid Test and Lab PCR testing and that there is a potential for false positive or false negative results. I hereby consent for myself, my heirs, executors, administrators, assigns, or personal representatives, and knowingly and voluntarily agree to have my sample collected by Provider and analyzed by the Rapid Test and/or Lab PCR Test and hereby forever waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in this activity.
  15. I hereby release and forever discharge Ann Jarris MD, PC (D/B/A DHMD), its affiliates, managers, members, physicians, contractors, licensors, subcontractors, supporting entities, agents, staff, attorneys, volunteers, heirs, representatives, predecessors, successors, and assigns (collectively “Provider”), Atlas Genomics and its principles, agents and staff and assigns and University of Washington and its principles, agents and assigns (“Labs”)  and the Port of Seattle, its Commissioners, officers, employees and agents (“Port Parties”)  for any physical or psychological injury, including but not limited to illness, paralysis, death, economic or emotional loss, or damage to property, regardless of how such injury or damage is caused, that I may suffer as a result of, related to, or arising from this Agreement or my participation in this activity, including, but not limited to, traveling to and from any location related to this activity.  In the event that I should require medical care or treatment, I agree and understand that I am financially responsible for any costs incurred as a result of such treatment.  I am aware and understand that I should carry my own health insurance.  I agree to indemnify defend, and hold harmless Provider, Labs and Port Parties against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation, defense or otherwise brought by me or anyone on my behalf, including attorneys’ fees and any related costs, arising out of or relating in any way to this Agreement.  If Provider, Labs or Port Parties incur any expenses in regard to a claim made by me or by anyone on my behalf, I am legally obligated and agree to reimburse the Provider, Labs and/or Port Parties for these expenses.
  16. I understand and acknowledge that Provider does not, and will not, bill health insurance for the services and testing performed under this Agreement. I understand and acknowledge that to the extent I wish for my health insurance to cover the cost of the Rapid Test and/or Lab PCR Test that it is my sole and exclusive responsibility to submit that claim and expense to my health insurer. I understand that Provider will not provide a physician’s order for any test conducted on an asymptomatic participant for the purposes of insurance reimbursement for a test required for recreational travel.  I further understand and acknowledge that full payment for Rapid Test and/or Lab PCR Test is due prior to any testing being performed, and that once made this payment is non-refundable.  Additionally, I understand and acknowledge that Provider accepts only the following methods of payment: credit or debit (VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS).
  17. If I complete this Agreement electronically, I will register and create an account on CASPIO. If I complete this Agreement in hard copy, I consent to the Provider uploading this Agreement, and all information provided thereon, to CASPIO.  I consent to the Provider maintaining and storing this Agreement, all information provided thereon including Personal Health Information, and my Rapid Test and/or Lab PCR Test result(s) on CASPIO and to moving and storing any of my information, including my Private Health Information, to any other HIPAA compliant database or storage system. I further consent to receiving communication from Provider or Labs regarding my Rapid Test and/or Lab PCR Test and the result(s) of said test(s) by voicemail, email or text at the phone number and email address I provided.  I understand that communication by email or text may not be encrypted and that voicemail may be intercepted by others.  I agree to accept the risk that my protected health information may be intercepted by persons not authorized to receive such information by consenting to communication with Provider by phone, voicemail, email or text.  Provider is not responsible for any privacy or security breaches that may occur through voicemail, email or text communications that I have consented to.  I have the right to withdraw my consent to receive email, voicemail, or text communications at any time, and can do so by submitting that request in writing to: For Abbott ID NOW: DHMD, 13075 Gateway Dr. S, Ste 100, Tukwila, WA 98168-3342.  For UW virology lab: 1616 Eastlake Ave E, Ste 320, Box 358115, Seattle, WA 98102-3795. For Atlas Genomics: 2296 W Commodore Way, Suite 220, Seattle, WA 98199.
  18. This Agreement, and the resolution of any and all disputes related to this Agreement, shall be construed in accordance with the laws of the State of Washington, without regard to conflict of laws principles. Any dispute between, or regarding, this Agreement shall be resolved exclusively in King County, Seattle, Washington and the parties expressly consent to personal jurisdiction in Seattle, Washington.
  19. In the event any dispute shall arise regarding or related to this Agreement, it is hereby agreed that the dispute shall be referred to the Washington Arbitration & Mediation Service, or alternate service agreed to by the parties, for arbitration in accordance with the Washington Arbitration & Mediation Service Rules of Arbitration. The arbitrator’s decision shall be final and legally binding and judgment may be entered thereon.  Each party to the arbitration shall be responsible for its share of the arbitration fees in accordance with the applicable Rules of Arbitration. In the event a party fails to proceed with arbitration, unsuccessfully challenges the arbitrator’s award, or fails to comply with the arbitrator’s aware, the other party is entitled to costs of suit, including a reasonable attorney’s fee for having to compel arbitration or defend or enforce the award.   THIS CONTRACT CONTAINS A BINDING ARBITRATION PROVISION WHICH AFFECTS YOUR LEGAL RIGHTS AND MAY BE ENFORCED BY THE PROVIDER, LABS AND/OR PORT PARTIES.
  20. The entire agreement between the Participant and the Provider is expressly set forth in this Agreement. The Parties are not bound by any agreements, understandings, provisions, conditions, representations, or warranties (whether written or oral and whether made by Provider or Participant or any agent, employee, contractor, parent, guardian, officer or principal of the Parties) other than as are expressly set forth in this Agreement.  No provision of this Agreement shall be construed by any arbitrator, court or other authority against any party hereto by reason of such party’s being deemed to have drafted or structured such provision.
  21. If I am a parent or legal guardian that is completing and executing this Agreement on behalf of a Participant under 18 years of age, I represent, warrant and agree that: (i) I am the Parent and/or Legal Guardian of the Participant; (ii) I have completed this agreement and provided consent on behalf of Participant; (iii) I acknowledge and consent to be bound to this Agreement on behalf of myself and on behalf of Participant; (iv) I personally guaranty Participant’s performance of this/her/their obligations under this Agreement; and (v) I accept full and complete financial responsibility for all services rendered by Provider to Participant under this Agreement.

I UNDERSTAND, ACKNOWLEDGE AND AGREE THAT I HAVE READ, UNDERSTOOD, AN AGREED TO THE STATEMENTS CONTAINED WITHIN THIS AGREEMENT.  I HAVE BEEN INFORMED ABOUT THE PURPOSE OF THE RAPID TEST AND/OR LAB PCR TEST, PROCEDURES TO BE PERFORMED, POTENTIAL RISKS AND BENEFITS, AND ASSOCIATED COSTS.  I HAVE BEEN PROVIDED AN OPPORTUNITY TO ASK QUESTIONS BEFORE PROCEEDING WITH A RAPID TEST AND/OR LAB PCR TEST AND I UNDERSTAND THAT IF I DO NOT WISH TO CONTINUE WITH THE COLLECTION, TESTING OR ANALYSIS OF THE RAPID TEST AND/OR LAB PCR TEST, I MAY DECLINE TO RECEIVE THESE SERVICES.  I HAVE READ THE CONTENTS OF THIS FORM IN ITS ENTIRETY, AND HAVE ANSWERED ALL QUESTIONS POSED TRUTHFULLY, AND VOLUNTARILY CONSENT TO UNDERGO RAPID TESTING AND/OR LAB PCR TESTING.

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