Terms and Conditions
Purpose of this Agreement
Terms of the Agreement
- Participant disclosures. 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. I attest and warrant that the statement above is truthful. I attest and warrant that, regardless of my test result, I will not board or travel on an airplane if I have any of the above listed symptoms, or 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.
- Informed consent. I have reviewed and read the relevant FDA Fact Sheets for Patients for the applicable rapid and lab PCR tests. I understand that my participation is entirely voluntary, and that the FDA has allowed the use of these tests under an emergency access mechanism called an Emergency Use Authorization (EUA), even though they have not been formally approved.
- I authorize Provider to collect a respiratory specimen through a nasal swab and to analyze it with the Rapid Test, and to package, transport and deliver the specimen to the Lab for analysis using a Lab PCR Test.
- I understand that I am not creating a patient relationship with the Provider or ordering physician. The Provider is not my medical provider and does not offer medical advice. I assume full responsibility for my medical care and agree to seek advice from my own provider if I have concerns or develop symptoms.
- I understand that Provider will provide my Rapid Test result directly to me, and that I will access my Lab PCR Test result online using the QR code and portal provided at the time of collection.
- I understand that Provider will not provide my Rapid Test or Lab PCR Test result to my health care provider or to any airline.
- I acknowledge and agree that Provider may disclose my result and the information on this Agreement to federal and state agencies and public health authorities, the employer I identified, and any entity or agency that paid Provider for the services rendered.
- I acknowledge that a positive result indicates that I am not fit to travel and that I shall immediately isolate for at least ten (10) days, and that I will notify any individuals I reside with or who are on my travel itinerary.
- I acknowledge that a negative result is not a guarantee that I am not currently infected, and that if I have symptoms I may have an active infection and am not fit to travel.
- I acknowledge that if I am not quarantined or isolated while ill, I could pose a substantial and direct threat to my own safety and to the health and safety of others, including everyone I come into contact with during air travel.
- I acknowledge that Provider is under no obligation to provide further, repeat, or confirming testing of my result.
- I recognize there are inherent risks associated with specimen collection and analysis, including the potential for false positive or false negative results. I knowingly and voluntarily consent to testing and waive any and all claims arising out of my participation, for myself and my heirs, executors, administrators, assigns and representatives.
- I release and forever discharge Ann Jarris MD, PC (D/B/A DHMD), its affiliates and agents (“Provider”), the Labs, and the Port of Seattle and its officers (“Port Parties”) from any injury or loss arising from this Agreement or my participation, and I agree to indemnify and hold them harmless. I am financially responsible for any medical care I require, and I am aware I should carry my own health insurance.
- I understand that Provider does not bill health insurance for the services and testing performed under this Agreement, and that submitting any claim to my insurer is my sole responsibility. Full payment is due prior to testing and is non-refundable. Provider accepts credit or debit (Visa, Mastercard, Discover, American Express).
- If I complete this Agreement electronically, I will register and create an account on CASPIO; if in hard copy, I consent to Provider uploading it. I consent to Provider maintaining my information, including PHI and results, on CASPIO or another HIPAA-compliant system, and to receiving communications by voicemail, email or text. I understand such communications may not be encrypted, accept that risk, and may withdraw consent in writing at any time.
- This Agreement is governed by the laws of the State of Washington, without regard to conflict of laws principles. Any dispute shall be resolved exclusively in King County, Seattle, Washington, and the parties consent to personal jurisdiction there.
- Any dispute shall be referred to the Washington Arbitration & Mediation Service for binding arbitration. The arbitrator’s decision is final and may be entered as judgment. Each party is responsible for its share of arbitration fees. This contract contains a binding arbitration provision which affects your legal rights.
- The entire agreement between the Participant and the Provider is expressly set forth in this Agreement. The parties are not bound by any other agreements, understandings, representations or warranties. No provision shall be construed against any party by reason of being deemed to have drafted it.
- If I am a parent or legal guardian completing this Agreement on behalf of a Participant under 18, I represent that I am the parent or legal guardian, consent on the Participant’s behalf, guarantee their performance, and accept full financial responsibility for services rendered.
Uses and disclosures we may make without your authorization
To contact you
Your information may be used to contact you to remind you about appointments or advise you about other health-related benefits and services.
Treatment
Your information may be shared with any healthcare provider who is providing you with health-care services. This includes coordinating your care with other health-care providers and providing referrals. We may share your information electronically with your health-care providers so they have your information as quickly as possible to treat you.
We may share your health information with any family member or friend who is involved in assisting with your health care. We will only do this if you agree or do not object, and will only share the information they need in order to help you. If you are unable to agree or object, we may disclose your health-care information as necessary if we determine it is in your best interest based on our professional judgment.
Payment
In order to obtain payment for your health-care services, we may have to provide your health information to the party responsible for paying. This may include Medicare, Medicaid or your insurance company, for activities such as determining eligibility for coverage, reviewing medical necessity, or providing approval for hospital services or stays.
Health-care operations
Your health information may be used in order to support our business activities and to assure that quality health-care services are being provided. Some of these activities include quality assessments, peer or employee review, training of medical personnel, licensure and accreditation, data aggregation and audits by regulatory agencies. We may share your PHI with third parties who perform services such as transcription or billing. In those cases, we have written agreements that they will not use or disclose your health information except if permitted by law.
