COVID-19 TESTING AND TRACING: INFORMED CONSENT FORM
The purpose of this form is to obtain your consent to participate in California Rural Indian Health Board, Inc. (CRIHB)’s collaboration with AB MED SOUTHWEST, LLC (AB MED) and their affiliates to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test and to contain community spread. Please carefully read the items on this form and indicate your acknowledgement and consent to the following. Consent to Participate
- I voluntarily consent to participate in CRIHB’s collaboration with AB MED and each of their affiliates to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test and to contain community spread. I acknowledge and agree that my participation is entirely voluntary, and I may choose not to participate.
- I acknowledge and agree that through the provision of the COVID-19 diagnostic testing, tracing and related services, CRIHB and AB MED may receive, maintain, use and/or disclose my personal health information. CRIHB and AB MED may contract with entities, government agencies, or individuals to help provide and facilitate these services; therefore, their contractors and affiliates (including but not limited to participating Tribal Health Programs and the California Tribal Epidemiology Center of CRIHB) may access, use and/or disclose my personal health information on a need to know basis to give me information about my test results, advise me of or carry out treatment, limit the spread of communicable diseases, conduct health care operations and for other purposes that are permitted or required by law.
- I understand that my sample will be sent directly to a third-party independent lab for processing and that my results may be pooled into an epidemiology study for the California Tribal Epidemiology Center of CRIHB. The results of these studies may be reported and published. However, under no circumstance will any of my personal information be disclosed for the purposes of these studies.
- To the fullest extent permitted by law, I hereby release, discharge and hold harmless, CRIHB and AB MED, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.