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Durham Public Schools COVID-19 Testing Program

Consent and Registration Form

We will use this email as the family’s user ID and send you a temporary password to give you access to our patient portal to get your results. (Este correo electrónico será utilizado como el nombre de usuario y le enviaremos una contraseña temporal para así darle acceso a su portal de paciente y ver sus resultados)
We need your email and phone number, if you have both, so we can contact you. (Necesitamos su correo electrónico y número de teléfono, si cuenta con ambos, para asi poderle contactar)

Consent-Full Consent Details At Bottom Of This Page (Consentimiento-Detalle completo de consentimiento al fino de esta pagina)

I am giving my school and Ottendorf Laboratories permission to test my child/children for COVID-19 by typing my name below. (Escribiendo mi nombre a continuación estoy dando permiso a la escuela y a laboratorios Ottendorf para practicar la prueba de COVID-19 a mi hijo/s)

PLEASE CLICK SUBMIT BEFORE LEAVING THIS PAGE (POR FAVOR DE CLICK EN SUBMIT ANTES DE ABANDONAR ESTA PAGINA)

Thank You! (¡Gracias!)

FULL CONSENT DETAILS IN ENGLISH AND SPANISH FOR STUDENTS

ENGLISH

PATIENT CONSENT TO PROVIDE COVID-19 TESTING

HIPAA PRIVACY AUTHORIZATION FORM

***Authorization for the Use or Disclosure of Protected Health Information

***(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

CONSENT TO COVID-19 TESTING

My child(ren) are receiving a COVID-19 Test by Ottendorf Laboratories, LLC at Durham Public Schools and I consent to this COVID-19 Test. I understand that I will receive education related to this testing in the form of a handout.

CONSENT TO USE OF INFORMATION

Electronic Health Records. I understand that Ottendorf Laboratories, LLC.  is collaborating with the State of North Carolina, the Department of Health and Human Services, State and County Health Departments and with Durham Public Schools to coordinate, manage and provide COVID-19 Testing to my child and I consent to the Ottendorf Laboratories, LLC’s sharing my health information and records electronically for the purposes of contact tracing, reporting results and payment.  The electronic health records (EHR) will be accessible by credentialed practitioners/practitioners as well as other individuals approved to access the EHR for purposes related to testing, contact tracing, payment and/or other purposes permitted by federal and state laws, including the Health Insurance Portability and Accountability Act (“HIPAA”). Ottendorf Laboratories, LLC has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of all medical information as required by HIPAA.

Request for Information from Others. I consent to Ottendorf Laboratories, LLC’s request of my child’s/children’s health information from other providers of care, receipt of and release of this health information, whether written, verbal, or electronic, only for the uses described above.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received or been offered a copy of Ottendorf Laboratories, LLC’s Consent to Use and Disclose Protected Health Information which provides information on how Ottendorf Laboratories, LLC may use or disclose PHI for purposes of contact tracing, reporting to the State of North Carolina, reporting to Durham Public Schools and/or payment.

FINANCIAL RESPONSIBILITY

I understand and agree that I am not financially responsible for payment of any charges incurred.  This COVID-19 Test is free of charge to me.  Ottendorf Laboratories, LLC will not ask for any insurance information and will not bill me for any charges.  The COVID-19 Test will be billed to the State of North Carolina.

EFFECTIVE PERIOD

This consent is only valid for one year from the date of my signature.

ESPANOL

CONSENTIMIENTO DEL PACIENTE PARA LA ADMINISTRACIÓN DE PRUEBA DE  DETECCIÓN DE COVID-19 HIPAA FORMA DE AUTORIZACIÓN DE PRIVACIDAD

***Autorización para el Uso o Revelación de Registros Médicos Protegidos

***(Requerimiento del Acta de Rendición de Cuentas y Portabilidad del Seguro Médico , 45 C.F.R. Parte 160 y 164)

CONSENTIMIENTO PARA PRUEBA DE COVID-19

A mi hijo/a/os se le aplicará prueba para la detección de COVID-19 por los laboratorios Ottendorf, LLC en Escuelas públicas de Durham y yo doy consentimiento a tal prueba. Entiendo que seré informado a detalle respecto a la prueba por medio de un  folleto.

CONSENTIMIENTO PARA EL USO DE INFORMACIÓN

Historial Médico Electrónico. Entiendo que los laboratorios Ottendorf, LLC. están colaborando con el estado de North Carolina, el Departamento de Salud y Recursos Humanos, el Departamento de Salud a nivel Regional Y estatal, y con las Escuelas Públicas de Durham para coordinar, dirigir, y proveer pruebas de COVID-19 a mi hijo/a y doy consentimiento a laboratorios Ottendorf, LLC de compartir mi información y registros médicos de manera electrónica con el propósito de rastrear contacto físico  en caso de infección, reporte de resultados, y pago.  Los Registros Médicos Electrónicos (RME) serán accesados por facultad médica acreditada así como otros individuos aprobados para tener acceso a RME para propósitos relacionados a pruebas de COVID-19, rastreo en caso de contacto con el virus, pago y/u otros propósitos permitidos por leyes federales y estatales, incluyendo Requerimiento del Acta de Rendición de Cuentas y Portabilidad del Seguro Médico (“HIPAA”). Laboratorios Ottendorf , LLC ha implementado garantías de seguridad administrativa, físicas, y técnicas que protegen de manera apropiada y razonable la confidencialidad e integridad de su registros médicos siguiendo los requerimientos de HIPAA.

Solicitud de Información. Doy consentimiento a los laboratorios Ottendorf , LLC a que soliciten información médica de mi hijo/a/os a personal de salud, recibimiento y liberación de esta información médica, ya sea por escrito, verbal, o de manera electrónica, solamente por los usuarios descritos en el párrafo anterior.

RECONOCIMIENTO DEL RECIBIMIENTO DEL COMUNICADO DE LAS PRÁCTICAS DE PRIVACIDAD

Yo reconozco haber recibido o haber sido ofrecido una copia de la forma de consentimiento para el Uso o Revelación de Registros Médicos Protegidos que me provee de información en cuanto a cómo los laboratorios Ottendorf, LLC pueden usar o revelar Registros Médicos Protegidos con propósito de  rastrear contacto físico  en caso de infección, reportar a el estado de  North Carolina, reportar a las escuelas públicas de Durham, y/o pago.

RESPONSABILIDAD FINANCIERA

Yo estoy de acuerdo y entiendo que no soy financieramente responsable por el pago de ningún. Esta prueba de detección de  COVID-19 es libre de cargo para mi. Laboratorios Ottendorf, LLC no solicitarán mi informacion de seguro médico, y no me harán ningún cargo financiero.  La prueba de detección de COVID-19 será facturada al estado de North Carolina.

PERIODO EFECTIVO

Este consentimiento sólo es válido por un año a partir de la fecha en que ha sido firmada.

FULL CONSENT DETAILS IN ENGLISH FOR STAFF

ENGLISH

PATIENT CONSENT TO PROVIDE COVID-19 TESTING

HIPAA PRIVACY AUTHORIZATION FORM

***Authorization for the Use or Disclosure of Protected Health Information

***(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

CONSENT TO COVID-19 TESTING

I am receiving a COVID-19 Test by Ottendorf Laboratories, LLC at Durham Public Schools and I consent to this COVID-19 Test. I understand that I will receive education related to this testing in the form of a handout.

CONSENT TO USE OF INFORMATION

Electronic Health Records. I understand that Ottendorf Laboratories, LLC.  is collaborating with the State of North Carolina, the Department of Health and Human Services, State and County Health Departments and Durham Public Schools to coordinate, manage and provide COVID-19 Testing to me and I consent to the Ottendorf Laboratories, LLC’s sharing my health information and records electronically for the purposes of contact tracing, reporting results and payment.  The electronic health records (EHR) will be accessible by credentialed practitioners/practitioners as well as other individuals approved to access the EHR for purposes related to testing, contact tracing, payment and/or other purposes permitted by federal and state laws, including the Health Insurance Portability and Accountability Act (“HIPAA”). Ottendorf Laboratories, LLC has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPAA.

Request for Information from Others. I consent to Ottendorf Laboratories, LLC’s request of my health information from other providers of care to me, receipt of and release of my health information, whether written, verbal, or electronic, for the uses described above.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received or been offered a copy of Ottendorf Laboratories, LLC’s Consent to Use and Disclose Protected Health Information which provides information on how Ottendorf Laboratories, LLC may use or disclose PHI for purposes of contact tracing, reporting to the State of North Carolina, reporting to Durham Public Schools and/or payment.

FINANCIAL RESPONSIBILITY

I understand and agree that I am not financially responsible for payment of any charges incurred.  This COVID-19 Test is free of charge to me.  Ottendorf Laboratories, LLC will not ask for any insurance information and will not bill me for any charges.  The COVID-19 Test will be billed to the State of North Carolina.

EFFECTIVE PERIOD

This consent is only valid for one year from the date of my signature.