Common use of Other Tests Clause in Contracts

Other Tests. In the event that a member of the hospital’s work force sustains a bodily fluid exposure during the course of my treatment, I consent to HIV testing and authorize the hospital to release the result of this said test to me, the exposed healthcare employee, and my physician. I understand that I have the right to refuse testing without penalty. I authorize I do not authorize Interpreter: If interpreter used, please complete the following: Interpreter ID Number (if phone/video interpreter used): Date: Time: Printed Name of Interpreter: Date: Time: Patient Signature: For health care agent / guardian / surrogate / parent / spouse (circle one), I, (print name), am the representative for the patient. Date: Time: Representative’s signature: Relationship to Patient: Date: Time: Pathology: ▇▇▇▇▇ ▇▇▇▇▇▇▇ may dispose of any tissue or parts that are removed during a procedure; may retain, preserve, use, and share these tissues, parts or related information for internal educational and quality improvement purposes without my permission (even when these tissues, parts or related information identify me); and may use or share tissues, parts or related information that identifies me for research with my permission or with the approval of a review board governed by federal laws protecting these activities. If tissues, parts or related information do not identify me, ▇▇▇▇▇ ▇▇▇▇▇▇▇ may use them for scientific (research) purposes without my permission or action by a review board.

Other Tests. In the event that a member of the hospital’s work force sustains a bodily fluid exposure during the course of my treatment, I consent to HIV testing and authorize the hospital to release the result of this said test to me, the exposed healthcare employee, and my physician. I understand that I have the right to refuse testing without penalty. I authorize I do not authorize Interpreter: If interpreter used, please complete the following: Remote In-person Interpreter ID Number (if phone/video interpreter used): Date: Time: Printed Name of Interpreter: Date: Time: Patient Signature: For health care agent / guardian / surrogate / parent / spouse (circle one), I, (print name), am the representative for the patient. Date: Time: Representative’s signature: Relationship to Patient: Date: Time: Pathology: ▇▇▇▇▇ ▇▇▇▇▇▇▇ may dispose of any tissue or parts that are removed during a procedure; may retain, preserve, use, and share these tissues, parts or related information for internal educational and quality improvement purposes without my permission (even when these tissues, parts or related information identify me); and may use or share tissues, parts or related information that identifies me for research with my permission or with the approval of a review board governed by federal laws protecting these activities. If tissues, parts or related information do not identify me, ▇▇▇▇▇ ▇▇▇▇▇▇▇ may use them for scientific (research) purposes without my permission or action by a review board.