VIP Testing Consent Form

CONSENT TO MEDICAL CARE AND TREATMENT: I, the undersigned, hereby knowingly and voluntarily authorize and consent to the collection and testing of specimens by VIP StarNETWORK and a laboratory to be designated by VIP StarNETWORK, for the purpose of COVID-19 testing. I authorize VIP StarNETWORK and laboratory to disclose the results of my COVID test to Wynn Las Vegas, LLC dba the Wynn | Encore Las Vegas Resort (“The Wynn Hotel”). I acknowledge that the COVID test results will be utilized by The Wynn Hotel to determine my eligibility to provide services for, attend an event at, or attend work at, The Wynn Hotel or any Wynn-related Properties.

I acknowledge that at the time of collection, a refusal to authorize the collection and testing of a specimen by VIP StarNETWORK and the laboratory, or a refusal to authorize the above disclosure of the test results, will be treated as a positive test result. I further acknowledge that a positive result will cause a disqualification from attending an event or to work at The Wynn Hotel pursuant to the policies and procedures then in place.

In addition, I hereby knowingly and voluntarily release The Wynn Hotel, VIP StarNETWORK, the collection site and the testing laboratory, their parent companies, subsidiaries and affiliates, their Members, and their respective officers, directors, employees and agents from any and all claims, damages, losses, liabilities, costs and expenses, including attorney fees, arising from or relating to such collection and testing and any disclosure of the results thereof, including without limitation, the disclosure of any inaccurate or incomplete results, to the fullest extent permitted by law.

I further authorize the testing laboratory to disclose the results of my COVID-19 test to The Wynn Hotel, or its agents, for a period of time not to exceed two years from the date of my signature below.

I understand that if an employee or any individual associated with VIP StarNETWORK is exposed to my blood or body fluids, I will be tested for the hepatitis viruses and the Human Immunodeficiency Virus (HIV). I also understand that I will receive education related to this testing and that I, or The Wynn Hotel, may be charged for testing related to the exposure.

CONSENT TO USE OF ELECTRONIC HEALTH RECORD: I understand that VIP StarNETWORK may collaborate with other health care providers to coordinate, manage and provide health care to me and I consent to VIP StarNETWORK sharing my health information and records electronically for the purposes of treatment, payment or operations, including improving the overall quality of health care services provided to me (e.g., avoiding unnecessary or duplicate testing, etc.). I consent to the inclusion in the electronic health records of sensitive diagnosis and related information such as HIV/AIDS status, sexually transmitted diseases, genetic information, and mental health and substance abuse. The electronic health records (EHR) may be accessible by other credentialed physicians/practitioners as well as other individuals approved to access the EHR for purposes related to treatment, payment, health care operations and/or other purposes permitted by federal and state laws, including the Health Insurance Portability and Accountability Act (“HIPAA”). VIP StarNETWORK has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPAA.

FINANCIAL RESPONSIBILITY: I understand and agree that I am financially responsible for payment of all charges incurred if not otherwise covered by The Wynn Hotel, including any and all products provided, or services rendered to me. I understand and agree that VIP StarNETWORK does not participate in my insurance network and will not bill my insurance.

PERSONAL VALUABLES: I understand that VIP StarNETWORK does not accept responsibility for any lost, stolen or damaged personal items while I am at VIP StarNETWORK.

I acknowledge that I have the right to receive a copy of this authorization.

I have read and understood the above Authorization & Consent in its entirety, and I agree that a copy of this document is as valid as the original.