AUTHORIZATION TO OBTAIN MEDICAL RECORDS FOR COVID 19 TESTING
PRINCIPAL OVERALL TESTING ADMINISTRATOR: Lori Layton, LPN / Jake Parrick, CEO
SUREGUARD TESTING PROGRAM NUMBER: 2022-O-001
PROTOCOL TITLE: COVID-19 Observational Testing Program
You are being provided with this consent as you are given access to the premises of a Healthcare Residence
which has retained Sureguard LLC, a Washington State limited liability company to conduct COVID 19
testing among its staff, residents and vendors. Please read the following consent form and sign on the reverse
side. Your signature will indicate that you have read and understood this document as well as provide
permission for us to obtain medical records pertaining to testing for COVID-19 and the ancillary results and
treatment therefrom.
Federal law requires that we, as test administrators , health care providers, and physicians’ networks, protect the
privacy of information that identifies you and relates to your past, present, and future physical and mental health
and conditions (protected health information). In this testing program, your protected health information will
continue to be used and shared with others as explained below. If you agree to the described uses within our group
(the healthcare residence at which you work, reside or visit, Sureguard LLC and affiliated testing laboratories) and
to the sharing of your protected health information with collaborators outside our group, then after reading this
entire document, please sign your name at the end of this form.
- Why will my protected health information be used or shared with others?
• To conduct and oversee the testing being conducted ;
• To ensure the testing meets legal, institutional, and accreditation requirements; and
• To conduct public health activities (including reporting of adverse events or situations where you or others
may be at risk harm). - A copy of our Company’s Notice for Use and Sharing of Protected Health Information, which provides
more information about how our test administration company and our affiliates use and share protected
health information will be provided to you upon request. - With whom may my protected health information be shared?
All reasonable efforts will be made to protect the confidentiality of your protected health information, which
may be shared with the following others for the reasons noted above:
• The Healthcare Residence as to which you seek access to their premises.
• The Company and its affiliated entities participating in the testing will use and share your protected health
information. ln addition, the Company’s review board that oversees the testing program and its affiliated
staff who have a need to access this information to carry out their responsibilities (for example, oversight,
quality improvement) will be able to use and share your protected health information.
• Outside individuals or entities that have a need to access this information to perform functions on behalf
of the Company and its affiliates (for example, collaborators reviewing and participating in PCR testing).
• Other billing contractors and medical centers participating in this testing , if applicable.
• Federal and state agencies (for example, the Department of Health and Human Services, the Food and
Drug Administration, the National Institutes of Health, and/or the Office for Human Research Protections)
or other domestic or foreign government bodies if required by law.
• A data and safety monitoring board organized to oversee this testing , if applicable.
We recognize that some of those who receive protected health information may not have to satisfy the privacy
requirements that we do and may re-disclose it, so we share this information only if necessary, and we use all
reasonable efforts to request that those who receive it take steps to protect your privacy. - What protected health information about me will be used or shared with others during this research?
• Existing self-reported information from questionnaires and previously-released medical records.
• New health information created from study-related tests, procedures, visits, and/or questionnaires.
- For how long will my protected health information be used or shared with others?
• There is no scheduled date at which your protected health information that is being used or shared for this
research will be destroyed, because testing is an ongoing process, during which information may be analyzed
and re-analyzed in light of scientific and medical advances, or reviewed for quality assurance, oversight, or
other purposes. - Statement of privacy rights:
• You have the right to withdraw or revoke your permission for the test administrators and participating entities to
use or share your protected health information. We will not be able to withdraw all of the information that
already has been used or shared with others to carry out the testing program or any information that has been
used or shared with others to carry out related activities such as oversight, or that is needed to ensure the quality
of the testing . If you want to withdraw or revoke your permission, you must do so in writing by contacting the
testing administrator listed below .
• You have the right to choose not to sign this form, which will prevent us from obtaining and using
information from your medical records related to the testing being undertaken. The consequences of choosing
not to sign and not participate in the testing should be discussed with your employer .
• You have the right to request access to your protected health information that is used or shared during this
testing program and that relates to your testing results or billing status at any time.. To request this information,
please contact the testing administrator listed below.
PLEASE COMPLETE THE FOLLOWING INFORMATION AND CLICK BELOW:
Concern: COVID-19 and ancillary conditions Date of Birth: _ – -/ —- /—–
YOUR FULL NAME AT THE TIME OF TEST: _
By clicking the acceptance button below , I grant permission to the Overall Principal Testing Administrator affiliated with
Sureguard LLC 5391 Maxwelton Road, Langley, Washington 98260, to use my healthcare history, the test administration
parameters, and the test results.
.
Ø Acceptance of Test Participant
Ø Acceptance of Court Appointed Guardian pr Health Care Proxy [Insert Name_______________________]
Ø Acceptance of Family Member or Next of Kin [Insert Name_____________________________________]
TESTING ADMINISTRATION CONTACTS:
Lori Layton LPN
5391 Maxwelton Road
Langley, Washington 93260
Tel: 360-914-5732