COVID-19 TESTING - Formstack

Was the patient scheduled

Yes No
Patient Information
Who scheduled this patient?
Name *

First Name Middle Name Last Name
Male

Male Female
Address If you are unable or unwilling to provide your current address you can use the facility address: 2950 E. Flamingo Rd. Suite E. Las Vegas, NV 89121 *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Ethnicity *

Hispanic or Latino. White Black or African American. American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander.
Email Address *
Cell Phone *
Social Security Number
Employment *

Employed Full time Part time Unemployed Disabled Retired
Current Employer
Would you like us to fax your CoVid-19 Results to your employer?

Yes No
Attention To?
Employer Fax #
Employer Email Address
Do you have a Driver's Licence , ID or Passport Number *

Yes No
ID Type
Driver's License/ ID Number /Passport Number
Front Picture of Driver's Licence , ID or Passport Number

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Cancel of
Insurance
Do you have active health insurance?* *

Yes No
Not to worry, CoVid-19 Testing is coverd under the Cares Act for the uninsured.
What type of insurance do you have?

A Federal health care program (as defined under section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)), including an individual who is eligible for medical assistance only because of subsection(a)(10)(A)(ii)(XXIII) of Section 1902 of the Social Security Act A group health plan or health insurance coverage offered by a health insurance issuer in the group or individual market (as such terms aredefined in section 2791 of the Public Health Service Act (42 U.S.C.300gg-91)), or a health plan offered under chapter 89 of title 5, UnitedStates Code.]
Primary Insurance Company's name:
Member ID
Group ID
Front of Insurance Card ID

Browse Files

Cancel of
Back of Insurance Card ID

Browse Files

Cancel of
Are you being tested: *

Drive-thru At your apartment complex
Make & Model of Car/SUV/Truck *
If doing drive-thru testing list car instead of apt.
Color of vehicle? *
Health Screening
Do you have any of the following symptoms? (Check all that apply)** *

Fever or chills (Fiebre o escalofríos) Cough (Tos) Shortness of breath or difficulty breathing (dificultad para respirar) Fatigue. (Fatiga) Muscle of body aches (Dolor muscular) Headaches (Dolore de cabeza) New loss of taste or smell (Nueva pérdida de sabor o olor) Sore throat (Dolor de garganta) Congestion or runny nose (Congestión o secreción nasal) Nausea or vomiting (Náusea o vómito) Diarrhea I don't have any symptoms
Do you have any of the following conditions? (Check all that apply) -* *

Obesity (Obesidad) COPD Congestive heart failure. (Insuficiencia cardíaca congestiva) Coronary heart disease. ( Enfermedad coronaria) Diabetes History of autoimmune disease ( Historia de enfermedad autoinmune) Immune deficiency (e.g. HIV). (Deficiencia inmune (por ejemplo, VIH) Cancer High blood pressure (Hipertensión) I do not have any of the above conditions ( No tengo ninguna de las condiciones anteriores)
Have you been in personal contact with anyone that has tested positive for CoVid-19?* *

Yes No
Have you tested positive for CoVid-19 previously *

Yes No
Should you test positive for CoVid-19 and make a full recovery, would you be willing to be tested free of charge, for antibodies to CoVid-19 and would you be willing to donate plasma to treat someone else?* *

Yes No
Financial Agreement
Under the Cares Act the cost for your CoVid-19 test will be covered by your insurance. If insurance is inactive or you don’t have insurance, your test will be processed through Cares Act for reimbursement. In the event that you omitted insurance information or provided incorrect demographic information that delayed billing, you will be responsible for any balance not paid by you insurance company. Do you understand?* *

Yes, and I agree
FFCRA Uninsured Individuals means individuals who, as of the date of service for which Recipient seeks Payment, are not enrolled in—§ A Federal health care program (as defined under section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)), including an individual who is eligible for medical assistance only because of subsection(a)(10)(A)(ii)(XXIII) of Section 1902 of the Social Security Act; or§ A group health plan or health insurance coverage offered by a health insurance issuer in the group or individual market (as such terms are defined in section 2791 of the Public Health Service Act (42 U.S.C.300gg-91)), or a health plan offered under chapter 89 of title 5, United States Code. *

I am uninsured
Signature of Patient/Responsible Party: By signing below I consent to the use of information I have provided to faciliate treatment of CoVid-19 and any of my medical conditions necessary per Partida Corona Medical Center or any medical facility I may be referred to by them. * *

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Hipaa Release Consent for Emailing Results
I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.HIPAA stands for the Health Insurance Portability and Accountability ActInformation stored on our computers is encrypted Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet.In addition, once the email is received by you, someone may be able to access your email account and read it. Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website‐ http://www.gpo.gov/fdsys/pkg/FR‐2013‐01‐25/pdf/2013‐01073.pdf The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted emailPATIENT CONSENT TO UNENCRYPTED EMAIL COMMUNICATIONSBy signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your health information via unencrypted email and hereby consent to receive such communications despite those risks. Messages containing clinically relevant information may be incorporated into the medical record at the provider’s discretion.By signing below, you also acknowledge that you have the choice to receive communications via other more secure means such as by fax. By signing below,you agree to hold Partida Corona Medical Center harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide. *

By clicking Yes you agree to abide by the consent terms outlined above.
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How did you hear about us?*

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Patient Information

Insurance

Health Screening

Financial Agreement

Hipaa Release Consent for Emailing Results