Self Assessment and Requisition for Testing

Patient Legal Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Minor?

Yes No
Parent/Guardian Name

First Name Last Name
Phone Number *
Address *

Street Address

Street Address Line 2

City State

Zip Code
County of residence *
Travis, Williamson, Bexar, etc.
Email *
example@example.com
Status

Single Married Other
Reason for requisition: *

Due to physician order Post vaccine antibody screen History of known exposure to Covid-19 History of probable exposure to Covid-19 History of confirmed past Covid-19 infection (PCR) History of probable past Covid-19 infection Suspicious symptoms of SARS Cov-2 Return from travel or evaluation of current status for travel Patient request Employer requested Return to work Required isolation or quarantine Positive past PCR test, desire to donate plasma post infection Travel requirement
If doctor requested please put name of doctor
Name of requesting doctor
If traveling internationally...
If international travel please enter PASSPORT NUMBER , EXPIRE DATE , COUNTRY OF ISSUE and this information will be added to your result report.
Example:
12345677897
12 MAY 2026
UNITED STATES OF AMERICA
Symptoms of Covid-19 per CDC

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue
Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea.

This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19.

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Date of Symptoms:

Month Day Year
Date
Are you symptomatic per CDC? *

YES NO
Have you been hospitalized? *

YES NO
Are you a resident in a care setting (including nursing homes, residential care for people with intellectual and developmental disability and care homes, homeless shelter, foster care or other setting? *

YES NO
Are you a healthcare worker currently working outside the home? *

YES NO
Gender *

Female Male
Are you a pregnant?

YES NO
Have you received a Covid 19 vaccination?

Yes No
If you answered Yes, you have received a Covid 19 vaccination please complete below:

Moderna Pfizer Johnson & Johnson
If you answered Moderna or Pfizer. Have you had both doses?

Yes, both doses No, just the first one
Full SSN (social security number)
This is for insurance look up as needed and for uninsured processing. If you do not have a SSN put in zeros.
Height *
feet.inches
Weight *
pounds
Race *

White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Unknown
Ethnicity *

Hispanic Non-Hispanic Unknown
Identification
Government Identification (if minor use parent or guardian ID) *

Browse Files
Driver's license, passport, Global Entry. Allowed file types pdf, jpg, jpeg, png, gif Cancel of
Insurance
Will you be using insurance to cover charges associated with testing?

YES NO (if you have insurance, at all, you cannot claim uninsured. Fees will be at the private rate.) *Effective November 1, 2021, neither Cigna nor any BCBS policy will cover surveillance testing or testing for travel. It will only be billable to insurance if you have symptoms or a known exposure. Uninsured
Type of Insurance (Skip if uninsured or not using insurance.)

PPO HMO *Patients using HMO policies may go with an in-network lab, you may use the private fee option or directly through the reference lab. For example: BCBS plans starting with ZGN are HMO policies. Consult your policy administrator for more information on approved labs. Medicare Medicaid/MAP/TX Healthy Woman/etc
Insurance Company Name:
Blue Cross Blue Sheild, Aetna, Cigna, etc....
Member ID#:
Group#:
Subscriber:

Self Spouse Parent/Guardian
If you're using insurance please take a photo of the front and back of your member card and enter the ID number and group number below.
Front of Insurance Card

Browse Files
Allowed file types pdf, jpg, jpeg, png, gif Cancel of
Date

Month Day Year
Back of Insurance Card

Browse Files
Allowed file types pdf, jpg, jpeg, png, gif Cancel of
I consent to the procedure for self or parent/guardian *

I consent for myself I consent as parent/guardian
Consent: I consent to the procedure for myself or as parent/guardian of named above, that may be performed during this visit including examination, emergency room referral, or services rendered to me as ordered by my physician or other health care professional. I voluntarily request and consent for independently contracted physicians to order all necessary tests and treatments. I understand that medical care is not an exact science and that no guarantee or warranty is being made as to my examination, treatment, result, or outcome. I understand that I am free to withdraw my consent and to discontinue participation in these tests at any time. Austin Covid Labs is owned by Michelle Paris, DC and Laurette Smith, MD. Results are for informational purposes only and does not propose a diagnosis. I understand that continuing on this form and booking an appointment indicates that the $100 testing/scheduling fee is not refundable. I understand that I may submit charges to my insurance company, but I may not be reimbursed.

Assignment of Benefits: I assign to Austin Covid Labs, Paris Medical Management PLLC all right, title and interest in any and all health insurance and/or health plan proceeds/benefits from any plan(s) arising from the provision of any good and services provided by Austin Covid Labs (ACL) and/or physicians/health care providers thereof. This Assignment is made in accordance with 1204.054 Tex. Ins. Code. This includes 3rd party claims. A lien will be assigned if needed for 3rd party claims and is irrevocable unless both patient and provider submit so in writing.

Acknowledgment and Signature: The above information is true to the best of my knowledge. I have read, understand, and accept the consents, policies, and terms as set forth above. I authorize WFC and ATX Covid Labs to release any information required to process my claims and act on my behalf in Appeals. I understand that the $100 testing/scheduling fee is non-refundable.

By signing below you allow us to email you your results and/or leave a voice message.

By signing below you agree to the HIPAA Consent form located at: www.austincovidlabs.com/hipaa
Signature (or signature of parent or guardian) *

Clear
Date *

Month Day Year
Date
Directions

4818 Berkman Dr. Ste 100

Austin TX 78723

Google Maps Link
Appointment
CC Processing Merchant: Austin Covid Labs | 4818 Berkman Dr. Suite 100, Austin, TX 78723 | US (512) 640-6990

My Products

Testing & Admin Fee - When using any Insurance (except Medicare, Medicaid or Tricare) or Uninsured for PCR test $ 100.00

Administrative & Testing Fee is not refundable should you miss or cancel your appointment; however, with 24 hours notice, we will gladly reschedule you for another date.

PCR

RAPID RT-PCR - Additional Pmt for Private, Travel, Foreign Nationals, No Medical Necessity $ 150.00

Abbott ID Now Rapid RT-PCR Test

Total $ 0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

If traveling internationally...

Identification

Insurance

Directions

Payment Methods