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Informed Consent Policy

Please carefully read and sign the following Informed Consent:

a) I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.
b) I authorize my test results to be disclosed to the county, state, or to any other government entity as may be required by law.
c) I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
d) I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regard to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
e) I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
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.

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Financial Policy

Please carefully review this Financial Policy, and sign the agreement to indicate your acceptance of its terms.

Payment is Due at the Time of Service
1. All payment for services are due prior to the time of service unless you have made payment arrangements in advance of your appointment. We accept debit and credit cards only.

Proof of Identification
1. Please bring a government issued photo ID with you to each appointment.

Billing and Refunds
1. We are not contracted with insurance; we are out of network. We can provide you a claims form if you would like to send it into your insurance company for a reimbursement.
2. If we must send you a statement, the balance is due in full within 30 days of the statement date.
3. We do not offer refunds. All sales are final.

Additional Information
3. The Privacy Rule allows you to receive a copy of your personal medical and billing records and allows the Practice to require individuals to complete and sign an Authorization for Disclosure and Release of Medical Records Form.
4. By agreeing to this section, I acknowledge that I have received and reviewed, or have been given the opportunity to receive and review, a copy of the Practice’s Notice of Privacy Practice, Public Fee Schedule, Statement of Patient’s Rights and Advanced Directive Statement.
5. By agreeing to this section, I acknowledge that Arizona Rapid Covid and Arizona Outpatient Anesthesia Consultants (AOAC) is a wholly owned subsidiary of Arizona Pain Specialists (APS) and I approve of AOAC sharing my patient records with APS.
6. By agreeing to this section, I acknowledge that Arizona Rapid Covid may send my test to a 3rd party laboratory.

Agreement and Assignment of Benefits
I have read and understand the Financial Policy of Arizona Rapid Covid/AOAC, and I agree to abide by its terms. I understand that I am financially responsible for all services I receive from the Practice. This financial policy is binding upon me and my estate, executors and/or administrators, if applicable.