COVID-19 Test

Consent and Authorization

I. COVID-19 Test Consent

I, the undersigned, agree that e3Health Solutions, LLC, doing business as eTrueNorth and its independent contractors (collectively, “eTrueNorth”) may provide me with a self-swab test (the “Test”) capable of diagnosing the novel coronavirus disease (“COVID-19”). Also, I acknowledge that I will administer this Test to myself, and I permit eTrueNorth to arrange for the clinical analysis and interpretation of the Test once the Test contains my specimen.

In addition, I understand and agree to the following:

  1. My eligibility to receive a Test will depend on objective, scientifically determined eligibility criteria established by the Centers for Disease Control and Prevention (“CDC”).
  2. I will administer the Test to myself, pursuant to the supervision of a pharmacist or other healthcare professional provided by the retail pharmacy group whose testing location I select (“Selected Retail Pharmacy Group”) among Walmart, Inc., or Health Mart Systems, Inc.,
  3. The Test will be analyzed and interpreted by one or more independent clinical laboratories (the “Labs”).

II. HIPAA Authorization

I hereby consent to and authorize (i) the disclosure of my completed Test to the Labs in order to permit the Labs to analyze and interpret my Test, and (ii) the disclosure of my Test results in any manner permitted by federal or state privacy and security laws. This consent and authorization is valid as of the day this document is signed by me and expires after one (1) year.

In addition, I understand and acknowledge the following:

  1. I understand that I have the right to revoke this consent and authorization at any time that I so choose by notifying eTrueNorth. If I revoke this consent and authorization, I understand that the revocation would only apply after I notify eTrueNorth.
  2. I understand that my consent and authorization will result in the use or disclosure of my protected health information. Though precautions will be taken to protect the confidentiality of this protected health information, I understand that the transmission of protected health information presents risks and that the confidentiality of such information may be compromised by failures of security safeguards or illegal tampering.
  3. I understand that I may receive a copy of this consent and authorization by accessing “DoINeedaCovid19test.com” or by calling (800) 635-8611.

III. Waivers

In consideration for receiving the opportunity to obtain a Test and considering that I am administering the test myself, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE eTrueNorth and its officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “eTrueNorth Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE ETRUENORTH RELEASEES OR OTHERWISE, ADMINSTERING A TEST TO MYSELF OR MY PRESENCE ON SELECTED RETAIL PHARMACY GROUP’S PROPERTY TO OBTAIN A TEST. I hereby accept and assume all risks to myself involved in administering a test to myself and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from such self-administration.

In addition, I also hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Selected Retail Pharmacy Group and its officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “Selected Retail Pharmacy Group Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE SELECTED RETAIL PHARMACY GROUP RELEASEES OR OTHERWISE, ADMINSTERING A TEST TO MYSELF OR MY PRESENCE ON SELECTED RETAIL PHARMACY GROUP’S PROPERTY TO OBTAIN A TEST. I hereby accept and assume all risks to myself involved in administering a test to myself and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from such self-administration.

I certify that (i) this document has been completely explained to me; (ii) I read this document or someone read it to me; (iii) all of my questions regarding this document have been answered; and (iv) I completely understand this document.

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