Sussex County COVID-19 Patient Testing Consent Form

I authorize a COVID-19 Test as ordered by my physician or authorized healthcare provider (or my child's or legal dependent's physician or authorized healthcare provider). I further understand, agree, certify, and authorize the following:

  1. The patient named above is a resident of Sussex County and has a valid prescription or laboratory order from a licensed physician or authorized healthcare provider for a COVID-19 test.
  2. I am the parent or legal guardian (if the patient is a minor or dependent) of the patient named above.
  3. I understand that the County of Sussex has contracted with Atlantic Health System for collection of my or my child/dependent's specimen as part of conducting a COVID-19 test. I authorize Atlantic Health System to collect the specimen.
  4. The County of Sussex has also contracted with BioReference Laboratories for laboratory analysis of the specimen taken by Atlantic Health System I authorize BioReference Laboratories to perform testing on the specimen to determine if the above named patient has COVID-19.
  5. I understand that processing of the specimen and results may take between 3 to 4 days, or possibly longer.
  6. I authorize and understand that BioReference Laboratories will release the COVID-19 test results to the County of Sussex Division of Health and Atlantic Health Systems.
  7. I authorize and understand that the County of Sussex Division of Health will release the results of my test to the physician or authorized healthcare provider who ordered the COVID-19 test. Results may be available for viewing by me at the BioReference Laboratories Patient Portal.
  8. I also authorize and understand that the County of Sussex Division of Health will release the COVID-19 test results to state and federal agencies as well as the patient's protected health information, which includes demographic information, as that term is defined under 45 CFR 160.103.
  9. I acknowledge that the County of Sussex Division of Health shall not provide the named patient with any medical advice and I understand that the physician or authorized healthcare provider identified in this online application will be responsible for providing testing results, interpreting test results, explaining testing limitations, and providing any additional diagnostic or clinical services.
  10. Treatment, payment, enrollment in a health plan, or eligibility for benefits may not be conditioned on signing this authorization.
  11. I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and submit it to the Sussex County Division of Health.
  12. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization and need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in 45 CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.
  13. I acknowledge that BioReference Laboratories and/or Atlantic Health Systems may have me execute addition forms and consents.

By selecting YES, I acknowledge and understand the following:

"I have read and agree to the Consent Form" field when making an on-line appointment, I acknowledge that I have read, understand, agree, certify, and/or authorize the information above and further agree to hold harmless the County of Sussex, BioReference Laboratories, Atlantic Health System, including its employees, agents, and contractors from any and all liability and claims.

I represent that I am electronically signing this consent voluntarily and intend to be legally bound by it.


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