COVID-19 Testing Registration Form

NATIVE HEALTH has been contracted by the Maricopa County Department of Public Health to assist in the County’s COVID-19 testing efforts. This testing unit, operated by Native Health on behalf of Maricopa County, is offering you COVID-19 testing using saliva based testing or nasopharyngeal swab. When you sign this form, you are agreeing to be tested for COVID-19 and with all of the statements included in this consent form.

Please carefully read and sign the following Informed Consent:

1. I consent and authorize the Maricopa County Department of Public Health, and its contractor NATIVE HEALTH, to conduct collection and testing for COVID-19 through a saliva test or nasopharyngeal swab, as ordered by an authorized medical provider or public health official.
2. I understand that Maricopa County and NATIVE HEALTH are not acting as my medical provider(s), this testing does not replace treatment by my medical provider(s), and I assume complete and full responsibility to take appropriate action with regards to my test results including self-isolation and wearing a mask or face covering as directed to avoid infecting others. I agree I will seek medical advice, care and treatment from my medical provider(s) if I have questions or concerns about this test or my health.
3. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. The Maricopa Department of Public Health and Native Health make no warranty and assume no responsibility for the accuracy of the testing. All testing results are provided on an “AS-IS” basis.
4. I authorize Native Health to disclose my name, contact information and test results to a county, state, tribal entity or to any other governmental organization as may be permitted or required by law.
5. To the fullest extent permitted by law, I hereby release, discharge and hold harmless, NATIVE HEALTH, including, without limitation, its respective officers, directors, employees, representatives, contractors, partners and agents, including, but not limited to, its lab testing subcontractors, and Maricopa Department of Public Health, 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 and the disclosure of my COVID-19 test results.
6. I understand that I may view a copy of the Maricopa County Department of Public Health’s HIPAA Notice of Privacy Practices (“NPP”) online at https://www.maricopa.gov/4348/Medical-Records and a copy of NATIVE HEALTH’s NPP at: https://www.nativehealthphoenix.org/services/medical/ privacy/

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.