Dear Parent or Guardian, One Love Laboratory is providing COVID-19
testing at the school listed
above. The laboratory is required to collect demographic information to
process each submitted test.
If you would like your child to be included in this voluntary program,
please complete the sections
below to provide consent.
Please sign the consent below:
I,, give permission for
to release any information
needed by the
laboratory for my child (Listed Above) to be tested weekly using the
Molecular PCR cheek or nasal
swab. I understand that this test causes no harm nor injury to my child.
I agree and authorize that
the cost of this test will be charged to my current insurance carrier
and I will incur no cost for
this test. I also understand that if my child does not have insurance,
the cost of the test will be
covered through the CARES ACT through the laboratory. I understand that
all test results will be
reported to me via text or email. I can be contacted at for
all test results.
Consent/Insurance Release: I, the undersigned, understand and grant permssion to
to bill my insurance for laboratory services provided. I undrerstand
that
services provided may not be covered by my insurance. I further understand that I will not be
responsible for co-pays, deductibles, andany amount not covered by my insurance. By signing below, I
acknowledge that payment may be made on my behalf to One Love Laboratory. I hereby authorize the
ordering physocan and/or clinic to disclose any personal or medical information that may be needed
to process claims related to services rendered by One Love Laboratory and its affiliates. I
understand that my records may be protected under 42 CFR Part 2, under which i may
revoke my consentat any time execpt to the extent that action has been takenin reliance on it, and
that in anyevent this consent expires six(6) months after the date of program discharge.
 }})