YOU EXPRESSLY ACKNOWLEDGE THAT IN OFFERING THE DMGAPP, DISASTER MANAGEMENT GROUP, LLC, (“DMG”), AND PROMERO, INC. (“PROMERO”) ARE NOT LICENSED PROVIDERS, AND DO NOT PROVIDE ANY SERVICES FOR MEDICAL EMERGENCIES OR URGENT SITUATIONS. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR DOCTOR OR 911 IMMEDIATELY. YOU SHOULD CONTACT YOUR HEALTHCARE PROVIDER IF YOUR SYMPTOMS GET WORSE OR YOU EXPERIENCE ANY NEW SYMPTOMS. BY SIGNING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT SIGN THIS CONSENT, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
You agree to receive the services provided by DMG, PROMERO, and certain other affiliated professional entities (collectively, “DMG”, “we” or “us”) relating to scheduling appointments for diagnostic testing for COVID-19 (“Test”), including, without limitation, creation of a user profile, participation in a survey to evaluate symptoms based on CDC guidelines, scheduling of a Test (if appropriate), receipt of Test results (“Results”), which may involve the storage of personal health and other information protected under federal and state laws, and you expressly authorize the sharing and reporting certain personal health and other information (the “DMG Services”). All testing for COVID-19, including services provided by physicians at testing sites, will be provided through outside third-party organizations
You acknowledge and agree to the following:
- You are (or your child or legal dependent is) the individual who will provide the sample for the Test that you are requesting.
- You are the parent or legal guardian (if the individual providing the same is a minor or dependent) of the individual who will provide the sample for the Test that you are requesting.
- You have read and understand the CDC information provided about testing on DMG’s website, including the following links:
- The information you have provided in connection with the DMG Services is correct to the best of your knowledge. You will not hold DMG responsible for any errors or omissions that you may have made in providing such information.
- Your personal health and other information and results may be shared with other local, state and federal departments of health, research facilities, and health care providers, including physicians, and counselors for purposes of providing care to you, and for compliance with COVID-19 reporting requirements.
- The DMG Services do not constitute treatment of any condition, disease or illness.
- DMG Services for scheduling are not determinative and are solely a recommendation of if you should consider testing. These recommendations are no way an indication of if you are likely to test positive or negative for COVID-19. Even after your testing is completed with an approved testing facility, there is a chance of a false positive or a false negative result. You are responsible to follow up with the testing facility if you do not receive results within twenty four (24) hours after you provide your sample.
- You are responsible for checking the scheduling mobile application or your e-mail for notice of where your results notification is available and options for viewing your results when available.
- You are responsible for forwarding any results to your primary care or other personal physician and for initiating follow up with such physician for care, diagnosis or medical treatment.
- You will not make medical decisions without consulting a healthcare provider or disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of the DMG Services.
- If You receive an abnormal result, your name, result and personal health or other information may be disclosed to my state health agency in accordance with applicable law.
You understand that Test results are provided independent of DMG Services, and will be delivered by health care providers who may not be in the same physical location as you, may be using electronic communications, information technology or other means, including the electronic transmission of personal health information. You also understand that:
- You may need to see a health care provider in-person for diagnosis, treatment, and care. You authorize DMG to use the email address and phone number you provided at the time you requested the Test (or that
You updated by contacting DMG) to contact you in connection with the DMG Services. You are responsible for updating your user account or contacting DMG to notify them of any changes to your mailing address, email address, phone number or other information that you provided in connection with the DMG Services.
You understand that testing is voluntary and that you may withdraw your consent to testing at any time prior to the completion of the Test by cancelling your testing appointment through the mobile application.
By selecting YES on the “I have read and agree to the Consent Form” field when making an on-line appointment, you acknowledge that you have read, understand, agree, certify, and/or authorize the information above and further agree to hold harmless DMG including its employees, agents, and contractors from any and all liability and claims.
AUTHORIZATION/ MEDICAL RELEASE OF INFORMATION
You specifically authorize the transfer and release of your information as described herein and in the applicable Provider’s Notice of Privacy Practices, including your medical history that you provided, your Test Results and other identifiable health information, submitted by you or about you or your child or legal dependent in connection with the DMG Services, to, between and among yourself and the following individuals, organizations and their representatives: (a) DMG and its affiliates, their staff and agents; (b) the Provider and its affiliates, and their staff, agents, and health care providers, including physicians, to facilitate and execute the DMG Services requested by you or performed with your consent and as required or permitted by law; (c) the CDC, major research universities, and others for their research activities related to COVID-19. You understand that you have a right to receive a copy of the above data disclosure authorization. You have the right to refuse to agree to this authorization in which case my refusal may affect the DMG Services provided to you. When you or your child or legal dependent’s information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. You have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization. This authorization will expire ten (10) years from the date of signature. Your written revocation must be submitted to [Support] at: [[email protected]] By selecting YES on the “I have read and agree to the Authorization Form” field when making an on-line appointment, you acknowledge that you have read, understand, agree, certify, and/or authorize the information above and further agree to hold harmless DMG including its employees, agents, and contractors from any and all liability and claims.