By acknowledging, I understand and agree to the following:
I allow my sample to be tested, and I am consenting to the use of the data you collect to be used in a manner which protects my privacy from third parties, but which also allows SDI Labs to conduct research and to address evolving healthcare circumstances in our communities.
The information you provide, including your demographic information, symptoms, pre-existing conditions, current medications, and other data will be used to improve the care you receive. SDI Labs’ research division exists alongside but is separate from SDI Labs testing division. All studies are open-ended and exist to improve medical treatment outcomes. New features and surveys may be added on a continuing basis, and we may invite you to participate in these activities should they arise. We may also invite you to participate in specific studies if your self-reported information matches an area of interest for improving health and testing outcomes. Such invitations will be sent through routine communication methods such as email. SDI Labs would like to thank you for providing your information and helping us control the spread of COVID-19 virus.
By acknowledging, I agree that the test results of the test performed on my specimen by SDI Labs or any of its affiliates may be disclosed to any government agency or office pursuant to applicable law, rules, or regulations. I acknowledge that the aforementioned test results may also be disclosed to an employer, a school district, or other third- party in association with you and that maintains a current Business Associate Agreement with SDI Labs, Inc. thereby allowing them to receive information in accordance with the BAA. Such disclosures may include some or all of my personally identifiable information. I consent to all such disclosures and wave all rights you may have to restrict or object to any such disclosures.
By acknowledging, I understand and take full responsibility for the potential risks and complications associated with the testing procedures. such as possible discomfort or other complications that may happen during collection. I understand that there may be possible inconclusive test results, false positive, or false negative results.
Further information regarding SDI Labs HIPAA & Privacy can be found here.
We appreciate your choosing SDI Lab’s services. At SDI Labs, we value our professional relationship with you and would like to offer the following, as our payment policy.
By acknowledging I am agreeing to and acknowledging that I have read & understood the following policies:
I authorize my insurance company to pay SDI Labs Inc. all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges for services rendered whether or not it is covered by my insurance and that all payments are due when services are rendered. I understand that obtaining insurance coverage and benefit information is my responsibility and not the responsibility of SDI Labs. I understand that the relationship is between myself, the insured, and my insurance company If SDI Labs Inc. does not receive payment from my insurance company within six weeks after submission of claim, and/or SDI Labs Inc. finds my insurance is inactive/invalid, I agree to pay for all the tests in full. I understand that in the event of duplicate payments, my account will be reimbursed. I authorize the use of this signature on all insurance submissions.
I authorize SDI Labs to release protected health information under the following terms and conditions: 1) Patient information related to the tests performed at SDI Labs and personal information if responsible party and policy holder required by my insurance company to get insurance claims processed and paid, 2) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and 3) to HHS when it is undertaking a compliance investigation or review or enforcement action.
For your convenience, we accept cash, American Express, Visa, MasterCard, Discover.
Informed Consent for a minor under 18 years of age:
By acknowledging I give permission for my child to receive testing provided by SDI Labs, Inc. The steps of treatment/testing have been explained to me and my questions answered to my satisfaction. I have reviewed and agreed to this informed consent form and payment policy in its entirety on behalf of my child.
