Free Covid Care - Consent Form (Each students needs their own form.)
I understand that FREE COVID CARE and its HEALTHCARE AFFILIATES will provide free Covid-19 related services for me (or my child) based on the information contained in this form.  
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ACKNOWLEDGEMENT AND AUTHORIZATION - I represent and affirm that I have read and understood the HIPPA Privacy Policy for FREE COVID CARE and its HEALTHCARE AFFILIATES and I hereby assign my insurance benefits ( if any) to the healthcare service provider. I herby authorize FREE COVID CARE and its HEALTHCARE AFFILIATES to release appropriate medical information required to process my claim either with my insurance provider or in accordance with the provisions of the CARES ACT. I authorize FREE COVID CARE and its HEALTHCARE AFFILIATES to contact me by telephone, email and text messages, which information I have supplied below, in accordance with all applicable HIPAA requirements. I authorize the release of any relevant and appropriate medical information about me ( or my child) to FREE COVID CARE and its HEALTHCARE AFFILIATES , and to the staff of FREE COVID CARE and its HEALTHCARE AFFILIATES, and to third-party payers, my employer and to other healthcare providers who may need this information for continuing care purposes. I further represent that the information I have provided is complete and accurate to the best of my knowledge. (Initial Below) *
NOTICE OF PRIVACY PRACTICES AND RIGHTS UNDER HIPAA I understand that by signing this consent form that I have read and understand  my  rights and protections under HIPAA ( https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html).  (Initial Below) *
NOTICE OF LABORATORY TESTING I understand that by signing this consent form I consent to specimen collection, testing, billing of and payment from third-party payers ( including insurance providers, if any) for services rendered by FREE COVID CARE and its HEALTHCARE AFFILIATES appropriately related to the specimen provided. I acknowledge that my test results ( or those of my child) may be released to FREE COVID CARE and its HEALTHCARE AFFILIATES and/ or myself upon proof of proper and verified identification of myself in accordance with HIPAA. (Initial Below) *
RISKS AND BENEFITS OF TESTING I acknowledge that I have been informed and that I understand the risks and benefits associated with the test, including the possibility of a slight discomfort in the nose and/or throat, the possibility of bleeding from the nose and the possibility of an inaccurate test result. I acknowledge that I have been informed and I understand that, as with any medical test, there is the possibility of a false positive or a false negative result. I understand that the testing unit does not replace treatment by my medical provider and I hereby assume complete and full personal responsibility to take appropriate action with regard to my test results in accordance with applicable CDC guidelines (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html). I agree that I will seek medical advice, care and treatment from my medical provider if I have any questions or concerns. (Initial Below) *
If my child is at school and noted as a close contact, the school can administer a COVID-19 Rapid test to support notification earlier than 24-48 hours for PCR test results. (Initial Below) *
Student Full Name (Only one student per form.) *
Student Birth Date *
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Student's Grade Level *
Parent Name *
Parent Signature (Type your name as signature) *
Parent/Guardian Contact E-mail *
Parent/Guardian Phone Number *
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This form was created inside of Bronzeville Academy Charter School.

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