COVID-19 Evaluation Form

COVID-19 Medical Screening Exam

Please fill in the form below
Consent
You are signing up for a COVID-19 medical screening examination. This screening program has been requested by the Marquette County Health Department due to the SARS-CoV2 (Coronavirus) Pandemic. You will be interviewed and examined by a physician in your vehicle. This exam may include pulse oxygenation, heart/lung evaluation, or other pertinent areas.  This examination will occur in a parking lot and may be visible by other people. The test is done by a nasal-pharyngeal swab (deep into your nose). The 40$ copayment is for the medical screening examination.

·         I understand that the information that is submitted in this form WILL NOT be reviewed until the face to face visit with the physician.

·         I understand this form is NOT for emergency use.

·         I understand to wear a mask and wait in my vehicle (with the window closed) until instructed by staff.

·         I understand that this information will be shared with the county health department to accommodate test tracking and contact tracing.

·         The testing information may be shared with my primary care physician it is indicated on the form.

Billing of Insurance and Payment

·         I understand that Singletrack Health will be submitting a bill one time to my insurance for this examination. Singletrack Health will not resubmit the bill for invalid insurance, non-covered service, or other reasons.

·         Singletrack Health works with most local/regional insurances but may not be able to bill my insurance if not in the network. Singletrack Health may be out of network for your insurance, and higher copay/deductible may apply.

·         I understand that Singletrack Health will collect a copayment prior to services being rendered. If my insurance pays in full, the copayment will be refunded to me via SQUARE within 90 days.

·         I understand that my insurance information will be collected and provided to the lab performing the test.

·         I will be contacted once testing results are back (generally within 1 week).

·         I may be advised to go to the emergency department based on my symptoms/examination.

·         This screening does not establish me as a primary care patient of Singletrack Health, and the physician-patient relationship is concluded after communication of test results unless additional arrangements are made.

·         I consent to submit information via this electronic form.

·         I consent to electronic signature.

·         I will be advised to isolate at home based on CDC guidelines

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INSURANCE AUTHORIZATION

I authorize payment of insurance benefits directly to my provider. I understand that I am personally responsible for charges not covered by my insurance including deductibles and co-payments. I also understand that fee estimates given to me by my provider are not a guarantee of payment by my insurance and are subject to variation based on my individual insurance carrier and my insurance plan.

AUTHORIZATION TO RELEASE INFORMATION:

I authorize the release of any medical or other information necessary to: another requesting physician (for continuation of care or referrals), an insurance carrier for processing of a claim for benefits, or to my requesting pharmacy/medical supply company for processing of a medication/medical device.

PRIVACY NOTICE

I have been advised of this office’s privacy notice and can obtain a copy upon request. The privacy notice is also available on our website: www.singletrackhealth.com.

PATIENT CENTERED MEDICAL HOME

I understand that I may be a part of the Patient Centered Medical Home. The Patient-Centered Medical Home (PCMH) is a care delivery model whereby patient treatment is coordinated through a patient’s primary care physician to ensure the patient receives the necessary care when and where they need it, in a manner the patient is able to understand.

           ELECTION TO ELECTRONICALLY TRANSMIT MEDICAL INFORMATION

I authorize Singletrack Health, P.C. to furnish a copy of the medical record of my treatment, my discharge summary, and/or a summary of care record to my specialty care physician, and/or any health care provider or facility identified in my plan of care to facilitate my treatment and continuity of care. I understand that information disclosed under this paragraph may include, among other things, confidential HIV-related information and other information relating to sexually transmitted or communicable diseases, information relating to drug or alcohol abuse or drug or alcohol dependence, mental or behavioral health information (excluding psychotherapy notes), genetic testing information, and/or abortion-related information. The summary of care record consists of information from my medical record, including information concerning procedures and lab tests, my care plan, a list of my current and historical problems, and my current medication list. I understand that I may revoke this authorization at any time by placing a written request to my healthcare provider. I understand that a healthcare organization is unable to take back information that has already been released under this authorization once transferred. I further understand that if I participate in the use of the patient web portal, I am responsible for the safeguarding of the computer I am accessing my personal information with and/or any information printed from the web portal by myself.
I agree to the above consent and privacy policies, and I certify that I am 18 years or older, or parent/guardian of the patient if the patient is a minor. *

I HAVE READ THIS CONSENTAND I AM FULLY AWARE OF AND AGREE TO THE CONTENTS
By signing below, I agree to all items in the COVID-19 Screening Consent *

Clear
The payment will NOT be refunded if the patient cancels or doesn't show up for the appointment *

I understand that the payment will not be refunded if the patient cancels or doesn't show for the appointment.

Health Insurance

Please enter your health insurance information.
Health Insurance Carrier *
Enrollee ID *
Group Number *
Effective Date *
Are you the SUBSCRIBER on the insurance card? *

Yes No I don't have insurance
Subscriber Name

First Name Last Name
Subscriber Date of Birth

Month Day Year
Subscriber Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have SECONDARY insurance? *

Yes No
SECONDARY Health Insurance Carrier
SECONDARY Enrollee ID
SECONDARY Group Number
SECONDARY Effective Date
Please submit a copy (front/back) of your insurance card(s)
FRONT of Insurance card

Front of insurance card

Cancel of
BACK of Insurance card

Back of insurance card

Cancel of

Advance Beneficiary Notice

Some insurances (Medicare included) won't cover all services. This form is to allow Singletrack Health to retain the copay in the event that your insurance considers the evaluation/diagnosis a "non-covered" service.
Advance Beneficiary Notice of Noncoverage (ABN). If Medicare (or your insurance) doesn't pay for COVID-19 Evaluation and Management, you may have to pay. Medicare (or your insurance) does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect that Medicare (or your insurance) may not pay for the COVID-19 Evaluation and Management (Insurance billable to 175$) due to screening or symptoms as non-covered. Read this notice to make an informed decision about your care. Ask us any questions at your appointment. Your choice signifies your electronic signature. Choose an option below: (If you want the service, you will need to choose the first box) *

**I want the COVID-19 Evaluation and Management. I want Medicare (or your insurance) to be billed for an official decision on Payment which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare (or your insurance) doesn't pay, I am responsible for payment, but I can appeal to Medicare (or your insurance) by following the directions on the MSN. If Medicare (or your insurance) does pay, you will be refund any payments I made to you, less co-pay or deductibles.

Appointment
Instructions:
- Wear a mask (homemade/cloth/bandana mask is fine)
- Stay in your vehicle after arriving, and await instructions from staff
- Please write your name on a sheet of paper to show through the window to staff as you arrive
- The doctor will come to your car and ask you to roll down the window
- If you are late and the screening has completed, you will need to come back another day (to be arranged with our office).
Make/Model/Color of your car? *
This is for us to help identify you in our parking lot
Schedule your Appointment *

Payment processed via SQUARE *

COVID-19 Medical Screening Exam CO-PAY $ 40.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Should be Empty:

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COVID-19 Medical Screening Exam

Consent

Demographics

Health Insurance

Advance Beneficiary Notice

Medical History

Testing Criteria/Symptoms

Appointment