Individual Company School

Site Number *

Select Company *

Select School *

Test Type

RT-PCR

RAPID

Traveller

Yes

First Name *

Last Name *

Gender *

Date of Birth * mm/dd/yyyy

Email *

Address*

City*

State*

ID Number* (any government issue ID number)

Do you have medical insurance? *

Yes

Phone#

Insurance Provider

Primary Care Provider

Policy#

Insurance Card Front Pic

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Consent to Test: I authorize the lab to test and release results to the ordering provider. Health Coverage: I authorize payments be made to the lab for the laboratory services ordered by my provider. I authorize my provider and provider’s medical staff, as well as my health plan providing medical benefits to release to the lab any information needed to determine coverage for laboratory services. I understand I am responsible for payment of any deductible and co-insurance charges. If my health plan providing medical benefits makes payment for laboratory service to me, I understand that I am responsible for making the payment to the laboratory for services rendered. Self-Pay: I accept full financial responsibility for payment associated with the laboratory tests ordered by my provider.

Patient Signature *

Picture ID Card * (State ID / Driving License / Pasport)

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Disclaimer

I hereby acknowledge that all information I have entered is true, accurate and best of my knowledge. Testing Company is not liable for any errors or omissions.

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