Parental Consent to Student PCR Testing - Extera Public Schools @ Breed Street Campus

1

Today's Date* This field is required.

Date

2

Student Name* This field is required.

First Name

Last Name

3

Student Gender* This field is required.

Female

Male

4

Student Date of Birth* This field is required.

Date

5

Student Home Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

6

Parent/Guardian Name* This field is required.

First Name

Last Name

7

Parent/Guardian Email* This field is required.You must have an email to receive testing results.

example@example.com

8

Parent/Guardian Mobile Phone* This field is required.

(###) ###-####

9

Student Race/Ethnicity* This field is required.

American Indian / Alaskan Native

Black / African American

White / Caucasian (Non-Hispanic)

Hispanic / Latino

Decline to identify

Asian

Other

10

Does the student have health insurance?* This field is required.

YESNO

11

Name of Primary Policy Holder* This field is required.

First Name

Last Name

12

Primary Policy Holder's Date of Birth* This field is required.

Date

13

Name of Health Plan or Insurance Company* This field is required.

14

Name of Health Plan* This field is required.

15

Upload a Picture of the Front of Your Insurance Card* This field is required.

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Max. file size: 10.6MB

16

Upload a Picture of the Back of Your Insurance Card* This field is required.

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Max. file size: 10.6MB

17

Insurance ID Number* This field is required.This will be listed as Insurance ID Number, Policy ID Number, or Member ID Number

18

Insurance Group Number* This field is required.This will be listed as "Group," "Group Number," or "Group #"

19

Does the student have a social security number?* This field is required.

YESNO

20

Student's Social Security Number* This field is required.

21

Does the Parent/Guardian have a Driver's License or ID card?* This field is required.

YESNO

22

Upload a picture of the front of the Parent/Guardian's Driver's License or ID* This field is required.

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Select files to upload

Max. file size: 10.6MB

23

Upload a picture of the back of the Parent/Guardian's Driver's License or ID* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

24

Consent for COVID-19 PCR (Molecular) Testing* This field is required.To provide a safe work environment and for the purpose of disease control and prevention, Extera Public Schools @ Breed Street Campus and its affiliates ("SCHOOL") require any individual entering a facility to undergo COVID-19 PCR (molecular) testing, which provides information about an individual's current COVID-19 status. As parent/guardian of ("Testee"), I consent to Flow Health Holdings LLC and subcontracted entities ("Company") administering the test and collecting information from the Testee as required for testing administration and by the Coronavirus Aid, Relief and Economic Security Act, including name, date of birth, address, gender, race, and ethnicity ("Testee's Information"). The Testee's COVID-19 PCR test results and the Testee's Information will be disclosed to SCHOOL pursuant to my written Authorization, only for the purposes of performing functions related to communicable disease prevention, control, and containment, including alerting others with whom the Testee have come into contact of possible exposure to COVID-19, monitoring the facility, and activities related to maintaining a safe environment. I understand that the Testee's COVID-19 PCR positive test results also will be disclosed to the applicable Public Health authorities and such Public Health authorities may contact me (on the Testee's behalf) directly. I understand that the Testee's ability to obtain treatment or payment for health services to which they are otherwise entitled will not be affected if I do not sign this Consent; however, if I do not sign, the Testee will not receive this COVID-19 PCR test, and it will affect their ability to enter the facility. I understand that neither the Testee nor I are not entering into a doctor-patient relationship with Company. The potential risks of taking the COVID-19 PCR test include possible discomfort and other complications that can occur during specimen collection. I also understand the possibility of incorrect test results. Those who test positive will be notified (and I may be contacted on behalf of the Testee) and directed to see their health care provider for further evaluation.

Clear

25

Name of the Minor ("Testee")* This field is required.

First Name

Last Name

26

Patient Consent and Authorization* This field is required.As parent/guardian of (“Testee”), I authorize Flow Health Holdings LLC and subcontracted entities (“Company”) to disclose the Testee’s personal health information to Extera Public Schools @ Breed Street Campus (“SCHOOL”) as set forth below. I allow Company to disclose the Testee’s personal health information, including the Testee’s COVID-19 PCR test results to School only for purposes of performing functions related to communicable disease prevention, control, and containment, including alerting others with whom the Testee has come into contact of possible exposure to COVID-19, monitoring the facility, and activities related to maintaining a safe environment. I understand that the Testee’s test results may identify them by name, date of birth, or other identifying information. If I do not sign this Authorization, Testee may not be authorized to enter School environments. I understand that once Company discloses the Testee’s personal health information to School, the Testee’s personal health information will no longer be protected by federal privacy law and may be subject to re-disclosure, consistent with this Authorization. School will take reasonable steps to protect the confidentiality of personal health information from disclosures other than disclosures for the purposes described above or as may be required by law. I can revoke this Authorization at any time by notifying Company in writing at Flow Health Holdings LLC, 8627 Washington Blvd. Culver City, CA 90232, and I understand that doing so will prevent future disclosures but will not affect the School's ability to use the Testee’s information they received before the revocation. This Authorization to Company is valid for one year from the date of my signature below and will expire on that date, unless revoked by me. School will retain the Testee’s information for one year. I have been advised that I have a right to receive a copy of this Authorization.

Clear

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Name of the Minor ("Testee")* This field is required.

First Name

Last Name