Ashewell Medical Group Testing Consent Agreement
SECTION A: CONSENT FOR COVID 19 TESTING AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT
I hereby CONSENT to allow ASHEWELL MEDICAL GROUP D.B.A SCOUT TESTING to take a specimen of my nasopharyngeal secretions and submit it for testing for COVID 19 virus.
In consideration for such services being rendered on my behalf, I hereby RELEASE ASHEWELL MEDICAL GROUP D.B.A. SCOUT TESTING, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against ASHEWELL MEDICAL GROUP D.B.A SCOUT TESTING, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS ASHEWELL MEDICAL GROUP D.B.A. SCOUT TESTING, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs
of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.
ASHEWELL MEDICAL GROUP D.B.A SCOUT TESTING will bill your credit card for the following tests based on the test performed:
$99.00 for your COVID PCR
$49.00 for COVID Lumira Dx Antigen Test
In consideration for such services being rendered on my behalf, I hereby RELEASE ASHEWELL MEDICAL GROUP D.B.A. SCOUT TESTING, its officers, agents, and employees, from claims related to billing the services rendered. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against ASHEWELL MEDICAL GROUP D.B.A SCOUT TESTING, their respective officers, agents or employees in connection with claims processed by my credit card processor. I hereby agree to INDEMNIFY and SAVE HARMLESS ASHEWELL MEDICAL GROUP D.B.A SCOUT TESTING, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to claims related to the credit card processor.
SCOUT TESTING
408 Depot Street
Asheville, North Carolina 28801
(828) 477-4077
SECTION B. CONFIDENTIALITY
Ashewell agrees to keep Patient’s information and medical records confidential and will not use or disclose it to others without permission during the term of this Agreement, except as required by this Agreement, or as required or permitted by law. Patient authorizes Ashewell to share his/her confidential patient
information with treating physicians, hospitals, health care facilities and licensed health care practitioners as necessary to provide medical services.
SECTION C. COMMUNICATION
By providing an email address above, Patient authorizes communication with Ashewell via email regarding Patient’s testing. Patient acknowledges the following:
1. Email is not necessarily a secure medium and there is the potential an unauthorized person/entity may gain access to the information.
2. Ashewell does not guarantee the confidentiality of electronic communications.
3. In the discretion of Ashewell, email communications may be made part of Patient’s medical record.
4. If Patient does not receive a response to an email message within one (1) day, Patient agrees to use another means of communication to contact Ashewell. Neither Ashewell nor the Physician shall be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including but not limited to power outages, internet outages, incorrect addresses, misuse, and/or malfunctioning hardware and/or software.
SECTION D. WAIVER OF BREACH
The waiver by either party of a breach of any provision of this Agreement by the other party (“Defaulting Party”) shall not operate or be construed as a waiver of any subsequent breach by such Defaulting Party.
SECTION E. NOTICES
Any notice or communication concerning this Agreement shall be in writing and shall be considered delivered when sent by United States first-class mail, postage prepaid, to the addresses provided in this Agreement. Either party may change its address by written notice to the other party.
SECTION F. ASSIGNMENT
This Agreement shall not be assigned whether individually or by operation of law by either party without
prior written consent, except that Ashewell may assign this Agreement to its successor without your consent in the event of any merger, consolidation, reorganization or acquisition of Ashewell.
SECTION G. GOVERNING LAW
This Agreement shall be governed in accordance with the laws of the State of North Carolina. Any litigation related to this Agreement or related to the services provided via this Agreement shall be brought exclusively in the state or federal courts located in Buncombe County, North Carolina and in no other venue.
The parties irrevocably consent to the jurisdiction of the courts in Buncombe County, North Carolina, whether federal or state, for all such disputes.
SECTION H. SEVERABILITY
Should any part(s) of this Agreement be determined to be invalid, unlawful or unenforceable, the validity of any other part(s) of this Agreement shall not be affected.
SECTION I. ENTIRE AGREEMENT; AMENDMENT
This Agreement contains the entire agreement between the parties and may be amended only by a written agreement signed by the parties.
SECTION J. PARAGRAPH HEADINGS; GENDER
Any titles, captions or headings in this Agreement are for convenience only, and are not part of this Agreement. References to gender include the masculine and feminine, as appropriate.