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Patient In-Take Form

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Patient Consent

By checking the general consent box below, I certify that I consent for Phosphorus to perform the test(s) ordered by the authorizing provider. I acknowledge that I am the patient providing the sample or the parent/guardian of the child providing the sample, and I am either (1) at least 18 years of age or (2) I am legally recognized as an ‘emancipated minor’ by the state in which I reside.

I hereby authorize Everpoint Medical, PLLC and Phosphorus to release the result of my COVID-19 test to Ethical Culture Fieldston School. The purpose of this disclosure is to provide information to the above listed individual/entity for infectious disease management. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient(s) and may no longer be protected by HIPAA Privacy regulations. I understand that I may refuse to sign this authorization; and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility for benefits except if the purpose of such test is to create information for disclosure such as an employment physical or independent medical exam.

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