SARS-COV-2 (PCR) A (COVID-19) TESTING REQUEST FORM

Please fill in the form below. One form must be completed for each patient.
Patients 17 and under must have a parent or legal guardian fill the form.

Patient Id:

Select Test Type: PCR

Organization ID(Ask Lab associate for the ID)

Phone Number

Is Minor

First Name

Middle

Last Name

DOB

Gender

Race

Ethnic Group

Address

City

State

Zip Not valid U.S. Zip Code!

Please upload front of State ID or Drivers license

Do you currently have medical insurance coverage?

Yes

Name of the Insurance

Insurance ID Number

Insurance Group number

Name of Insured

Relationship to insured

If you have medical insurance please upload front and back of your insurance card

Disclaimer

INFORMED CONSENT FOR COVID-19 DIAGNOSTIC TESTING

1. Authorization and Consent for Covid-19 Diagnostic Testing:

I understand that falsifying information on this form is criminal offence. I voluntarily consent and authorize Medlab Clinical Laboratory to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.

2. Patient Rights and Privacy Practices

Disclosure to Government Authorities: I acknowledge and agree that Medlab Clinical Laboratory may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.

3. Release

To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Medlab Clinical Laboratory, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.

By selecting the ACKNOWLEDGEMENT during the registration process for COVID-19 sDiagnostic Testing at Medlab Clinical Laboratory, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19

Medical insurance coverage

4. Insured Patients

If it is found that you have medical insurance and you select “NO Insurance” you will be held liable for payment.

5. Uninsured Patients

Reimbursement for COVID-19 testing is provided by Department of Health and Human Services; Health Resources and Services Administration (HRSA). HRSA requires individuals to provide a copy of their state issued identification card and signed attestation that they do not have any medical insurance at the time of testing. I Confirm and attest that I have no active health insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan. I understand if I fail to report active health Insurance I may be charged $138.00

Signature

Date Signed