Consent to Screening Testing
2781768 Ontario Limited o/s FH HEALTH
COVID-19 RAPID SCREENING TESTING INFORMATION FORM
FH Health provides COVID-19 testing for screening purposes. Faster testing with rapid results, means better identification and isolation of disease, and, ultimately, reduced community spread. This means that our members and their families can return to work or school as quickly as possible.
FH Health uses Health Canada-approved PCR rapid testing technology which is able to reliably detect the presence of the COVID-19 virus. Specimen collection is conducted by registered nurses, with oversight by a licensed medical professional. Our secure digital system allows users to book their test and confidentially receive their results. All testing, materials and processing is done independently. We do not access publicly available COVID-19 resources.
FH Health provides two types of screening testing:
1. Screening and Surveillance Testing for Organizations as part of an organization’s COVID-19 workplace screening program. For example, this may include an individual and their family members who have been requested by an employer, school, day care, church or other organization to take part in a COVID-19 screening testing program and to attend FH Health for this purpose.
2. COVID-19 Testing for Individuals whicwhich is limited to individuals who are not eligible for provincial COVID-19 testing and who require COVID-19 testing for the purposes of a third party (i.e. return to work, school, for the purposes of travel).
We recognize the need to maintain high standards for our services and the importance of privacy and confidentiality in every encounter with our patients. Please carefully review the following information.
CONSENT
Select the appropriate type of COVID-19 screening services:
SCREENING AND SURVEILLANCE TESTING FOR ORGANIZATIONS:
Your organization has engaged FH Health to provide COVID-19 screening and surveillance testing as part of a workplace program for its employees, contractors and their families, and/or school program to support the testing of students, faculty, and staff. Screening and surveillance testing is intended to help organizations identify infected individuals with or without, or prior to development of, symptoms so that measures can be taken to prevent further transmission. Arrangements have been made by your organization for you to attend one of our clinics or for mobile collection of specimens to take place for testing purposes. Your organization is responsible for developing its COVID-19 screening program and has determined when testing is advisable. With your consent, results of any COVID-19 testing for screening purposes will be shared with your organization.
COVID-19 TESTING FOR INDIVIDUALS:
FH Health makes COVID-19 testing in limited circumstances for individuals who require COVID-19 testing solely for the purposes of a third party (i.e. employer, school, for the purposes of travel).
Important:
FH Health does not provide COVID-19 testing to individuals who are eligible for COVID-19 testing in accordance with the Ontario Ministry of Health’s provincial COVID-19 testing guidelines. This includes individuals who are symptomatic, who have been exposed to a confirmed case of the virus as notified by local public health or the COVID Alert app, or live or work in a setting that has a COVID-19 outbreak as identified by a local public health unit. Individuals who require tests for the above purposes should follow the guidance of their health care provider and/or Ontario public health officials as appropriate and follow Ontario public health guidance and/or visit an Ontario COVID-19 Assessment Center, as applicable.
CONSENT FOR COVID-19 SCREENING TESTING
FH Health has been retained by my organization to provide COVID-19 (SARS-CoV) screening testing as part of its workplace COVID-19 Screening Testing Program (Screening Program).
Please select as appropriate:
I have been requested (or invited if applicable) to participate in my organization’s Screening Program (i.e. Employee / Student / Faculty)
OR
My child or other dependent for whom I am substitute decision maker has been requested (or invited if applicable) to participate in my organization’s Screening Program (i.e. Dependent)
OR
I have been requested (or invited if applicable) to participate in the Screening Program of my family member’s organization (i.e. Family member)
OR
I have requested COVID-19 Testing and hereby attest and represent that I have read the COVID-19 RAPID SCREENING TESTING INFORMATION sheet and provincial COVID-19 testing guidelines, and I do not meet the eligibility criteria for COVID-19 testing (i.e. individuals who are symptomatic, who have been exposed to a confirmed case of the virus as notified by local public health or the COVID Alert app, or live or work in a setting that has a COVID-19 outbreak as identified by a local public health unit). I am requesting COVID-19 testing solely for the purpose of a third party (i.e. work, school, airline).
I understand that COVID-19 Screening Testing will be performed by FH Health. The test will be requisitioned by an FH Health physician and the specimen will be collected by the FH Health nurse who will collect a sample using a deep nasal swab.
On the day of your appointment, the FH Health nurse will do a quick symptom check, will ask you some questions and perform a bilateral anterior nasal swab in the shallow nasal cavity [CONFIRM]. This test is not intrusive and is done in 30 seconds. Your specimen will be processed by FH Health or it will be sent to an accredited laboratory for processing. The results will be communicated to you by email.
In providing the COVID-19 Screening Services, I understand that it is necessary for FH Health and its staff to collect, use, retain, and disclose my personal health information (PHI) and to share such PHI with an external laboratory, as necessary. I understand that FH Health uses an online digital system for booking appointments and uses email communications to deliver results. I have had the opportunity to review and have agreed to be bound by FH Health’s Privacy Policy and Terms of Use. In addition to the collection, use and disclosure of PHI for the purposes of providing COVID-19 testing services, I agree that my PHI may be used for the following purposes:
ensuring the effective operation of the Screening Program;
providing information to my organization about a positive COVID-19 test result;
providing results to the FH Health physician who will report, as required by law, any positive COVID-19 test results to public health.
I understand that COVID-19 testing results will be communicated to me via the email address that I have provided. The use of technology may increase the risk of my PHI being unintentionally disclosed or intercepted by third parties. Technical failures and technological issues may result in a loss of PHI and/or delay or interruption. FH Health and the physician assume no responsibility or liability for any technical failures or technological issues associated with delivering results. I will notify FH Health if I do not consent to receiving electronic communications so that alternate arrangements can be put in place.
I understand that if my test indicates that I am positive for COVID-19, I will be contacted by email. Additionally, I understand that FH Health will notify my organization of the positive test result for the purpose of ensuring a safe workplace.
I understand that if my test indicates I am positive for COVID-19, the physician is required by law to report this to public health. Public Health will be provided with my name, address and phone number to enable contact tracing and the provision of COVID-19 support as needed.
I agree that should my test indicate a positive result for COVID-19 I will consult with public health and/or my own primary care physician or healthcare provider for specific advice that takes into account my medical history and personal health.
I understand and agree that this consent shall apply to this collection and any future collections under the Screening Program.
I may withdraw my consent for the collection, use and disclosure of PHI by refusing to participate in future COVID-19 screening testing and/or providing written notice to FH Health’s Privacy Officer. I understand that any withdrawal of consent is not retroactive.
I have been advised of the nature of the COVID-19 screening testing, expected benefits, risks, side effects, alternative courses of action and I have had the opportunity to ask questions about the COVID-19 screening testing to my satisfaction.
I consent to COVID-19 screening testing and for the collection, use and disclose of my PHI as described in this form.
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.