By signing below, I attest to the following:

I authorize Cayuga Medical to share my child’s test results with my child’s school for the sole purpose of identifying others who may have been exposed. I understand my child’s test results will be shared with the Tompkins County Health Department or any other governmental entity the law requires. The release of any legally privileged and confidential records (e.g. educational and/or medical records) will be in accordance with applicable privacy protection laws, including the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA).

I assume complete and full responsibility to take appropriate action with regard to my child’s test results. I acknowledge a positive test result is an indication my child must self-isolate and wear a mask or face covering as directed to avoid infecting others. I understand, as with any medical test, this COVID-19 test has the potential for false positive (test is positive but my child does not have the infection) or false negative (test is negative but my child has the infection) results. I agree to seek medical advice, care, and treatment from my healthcare provider if I have questions or concerns or if my child’s condition worsens. I understand the testing unit is not acting as a healthcare provider, and this testing does not replace treatment by a healthcare provider.

I understand the test purpose, procedures, possible benefits and risks, and I can request a copy of this consent form. I can ask questions before I sign this consent form, and I understand I can ask additional questions at any time.

I understand there will be no out of pocket charge for the tests, the costs will be covered by CARES Act funding.

I understand I can contact my child’s school at any time to revoke my consent and end my child’s participation in the testing program.

I understand that my student should not be sent to school with symptoms so that they can be tested.