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Covid19 Testing Appointment Request
Welcome to Epifania M. Caturay MDPA! Please fill out all required fields.
21
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HIPAA
Compliance
1
Patient Name
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First Name
Last Name
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2
Date of Birth
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Date
Month
Day
Year
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3
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Mexico
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Netherlands
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Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
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Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
San Marino
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Senegal
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Slovenia
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Somaliland
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South Sudan
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Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
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Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
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Turkey
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Turks and Caicos Islands
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Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
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Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Email
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The email that I authorize to receive email messages for appointment reminders and general health reminders/feedback/billing information
example@example.com
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5
Phone Number
*
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The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/billing information is: (The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).)
Area Code
Phone Number
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6
Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications
*
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Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, billing information and to provide general health reminders/information.If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information stated above at that email or text address from the Practice
I consent to receive text messages from PACGPA at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information/billing information unless I request a change in writing (see revocation section below) (Doy mi consentimiento para recibir mensajes de texto de PACGPA en mi teléfono celular y cualquier número enviado o transferido a ese número o correos electrónicos para recibir la comunicación como se indicó anteriormente. Entiendo que esta solicitud de recibir correos electrónicos y mensajes de texto se aplicará a todos los recordatorios de citas futuras / comentarios / información de salud / información de facturación a menos que solicite un cambio por escrito (consulte la sección de revocación a continuación)).
I DO NOT consent to receive text messages from PACGPA at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing (see revocation section below) (No doy mi consentimiento para recibir mensajes de texto de PACGPA en mi teléfono celular y cualquier número reenviado o transferido a ese número o correos electrónicos para recibir la comunicación como se indicó anteriormente. Entiendo que esta solicitud para recibir correos electrónicos y mensajes de texto se aplicará a todos los recordatorios de citas futuras / comentarios / información de salud a menos que solicite un cambio por escrito (consulte la sección de revocación a continuación)
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7
Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations- HIPAA (Consentimiento del paciente al uso y divulgación de la información de salud para tratamiento, pago u operaciones de atención médica: HIPAA
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I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my child’s protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of this consent. I understand that as part of my care, Pediatric and Adolescent Center of Grand Prairie & Arlington originates and maintains paper and/or electronic records describing their health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as a: - basis for planning my care and treatment; - means of communication among the many health professionals who contribute to my care; - source of information for applying my diagnosis and surgical information to my bill; - means by which a third-party payer can verify that services billed were actually provided, and - tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand and have been provided with a Notice of Information and Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: - the right to review the notice prior to signing this consent, - the right to object to the use of my health information for directory purposes, and - the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I understand that Pediatric and Adolescent Center of Grand Prairie & Arlington is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that Pediatric and Adolescent Center of Grand Prairie & Arlington reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Pediatric and Adolescent Center of Grand Prairie & Arlington change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email).
Comprendo que, como parte del tratamiento, pago u operaciones de atención médica de esta organización, puede ser necesario divulgar la información médica protegida de mi hijo a otra entidad, y doy mi consentimiento para dicha divulgación para estos usos permitidos, incluidas las divulgaciones por fax. Entiendo completamente y acepto los términos de este consentimiento. Comprendo que, como parte de mi atención, el Centro Pediátrico y para Adolescentes de Grand Prairie & Arlington origina y mantiene registros en papel y / o electrónicos que describen sus antecedentes de salud, síntomas, resultados de exámenes y exámenes, diagnósticos, tratamientos y cualquier plan de atención futura o tratamiento. Entiendo que esta información sirve como: - base para planificar mi atención y tratamiento; - medios de comunicación entre los muchos profesionales de la salud que contribuyen a mi atención; - fuente de información para aplicar mi diagnóstico e información quirúrgica a mi factura; - los medios por los cuales un tercero pagador puede verificar que los servicios facturados se prestaron realmente, y - una herramienta para las operaciones de atención médica de rutina, como evaluar la calidad y revisar la competencia de los profesionales de la salud. Entiendo y he recibido un Aviso de información y prácticas de privacidad que proporciona una descripción más completa de los usos y divulgaciones de la información. Entiendo que tengo los siguientes derechos y privilegios: - el derecho de revisar el aviso antes de firmar este consentimiento, - el derecho de objetar el uso de mi información de salud para fines de directorio, y - el derecho de solicitar restricciones sobre cómo mi información de salud puede usarse o divulgarse para llevar a cabo tratamientos, pagos u operaciones de atención médica. Entiendo que el Centro Pediátrico y para Adolescentes de Grand Prairie & Arlington no está obligado a aceptar las restricciones solicitadas. Entiendo que puedo revocar este consentimiento por escrito, excepto en la medida en que la organización ya haya tomado medidas al respecto. También entiendo que al negarme a firmar este consentimiento o revocar este consentimiento, esta organización puede rechazarme según lo permitido por la Sección 164.506 del Código de Regulaciones Federales. Además, entiendo que el Centro Pediátrico y para Adolescentes de Grand Prairie & Arlington se reserva el derecho de cambiar sus avisos y prácticas y antes de la implementación, de acuerdo con la Sección 164.520 del Código de Regulaciones Federales. En caso de que el Centro Pediátrico y para Adolescentes de Grand Prairie & Arlington cambie su notificación, enviarán una copia de cualquier notificación revisada a la dirección que he proporcionado (ya sea correo de los EE. UU.
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8
I understand that all information derived from this test will be kept confidential and released only to those I have identified on this form and health file. I also understand a documented chain of specimen custody exists to ensure the identity and integrity of my specimens throughout this collection and testing process. (Entiendo que toda la información derivada de esta prueba se mantendrá confidencial y se divulgará solo a aquellos que he identificado en este formulario y archivo de salud. También entiendo que existe una cadena documentada de custodia de muestras para garantizar la identidad e integridad de mis muestras durante este proceso de recolección y análisis.)
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9
Financial Policy (Política financiera)
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I understand that insurance co-payments, deductible, self-payment or outstanding balances are due at the time of the visit or test. We may refuse service if you have an unpaid balance. I hereby assign to PACGPA all insurance benefits, if any, otherwise payable to me for services rendered to myself and/or my dependent(s), and I hereby authorize and direct my insurance carrier to issue payment of such benefits directly to PACGPA, I authorize the use of my signature, and a copy thereof, on the insurance submissions. As a courtesy to our patients, we will file the insurance claims with your PRIMARY CARRIER (all Medicaid plans are considered secondary carriers.) We DO NOT become involved in any dispute between the insurance company and the member. The patient or responsible party is responsible for ALL fees. If for any reason we are unable to verify insurance information, full payment is required at the time services are rendered. We must have insurance information on file prior or during your visit for us to file any claims to the insurance company. Refund requests will take approximately 30-45 business days
Entiendo que los copagos del seguro, el deducible, el pago propio o los saldos pendientes se deben al momento de la visita o prueba. Podemos rechazar el servicio si tiene un saldo impago. Por la presente, asigno a PACGPA todos los beneficios de seguro, si los hubiera, que de otra manera me pagarán por los servicios prestados a mí mismo y / o a mis dependientes, y por la presente autorizo y ordeno a mi compañía de seguros a emitir el pago de dichos beneficios directamente a PACGPA, I autorizo el uso de mi firma, y una copia de la misma, en los envíos de seguros. Como cortesía para nuestros pacientes, archivaremos los reclamos de seguro con su TRANSPORTE PRIMARIO (todos los planes de Medicaid se consideran portadores secundarios). NO nos involucramos en ninguna disputa entre la compañía de seguros y el miembro. El paciente o la parte responsable es responsable de TODAS las tarifas. Si por alguna razón no podemos verificar la información del seguro, se requiere el pago completo en el momento en que se prestan los servicios. Debemos tener la información del seguro en el archivo antes o durante su visita para que podamos presentar cualquier reclamo a la compañía de seguros. Las solicitudes de reembolso demorarán aproximadamente entre 30 y 45 días hábiles
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10
I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official. (Autorizo a esta unidad de prueba de COVID-19 a realizar la recolección y prueba de COVID-19 a través de un hisopo nasofaríngeo o extracción de sangre, según lo ordene un proveedor médico autorizado o un funcionario de salud pública.)
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11
I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. (Autorizo que los resultados de mis exámenes se divulguen al condado, estado o cualquier otra entidad gubernamental según lo exija la ley.)
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12
I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.(Reconozco que un resultado positivo de la prueba es una indicación de que debo auto aislarme y / o usar una máscara o una cubierta facial como se indica en un esfuerzo por evitar infectar a otros.)
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13
I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. (Entiendo que la unidad de prueba no está actuando como mi proveedor médico, esta prueba no reemplaza el tratamiento de mi proveedor médico y asumo la responsabilidad total y completa de tomar las medidas apropiadas con respecto a los resultados de mi prueba. Estoy de acuerdo en que buscaré consejo médico, atención y tratamiento de mi proveedor médico si tengo preguntas o inquietudes, o si mi condición empeora.)
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14
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. (Entiendo que, como con cualquier examen médico, existe la posibilidad de un resultado falso positivo o falso negativo de la prueba COVID-19.)
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15
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19. (Yo, el abajo firmante, he sido informado sobre el propósito de la prueba, los procedimientos, los posibles beneficios y riesgos, y he recibido una copia de este Consentimiento informado. Se me ha dado la oportunidad de hacer preguntas antes de firmar, y me han dicho que puedo hacer preguntas adicionales en cualquier momento. Acepto voluntariamente esta prueba para COVID-19.)
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16
Name of Person Completing this form if other than the patient:
First Name
Last Name
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17
Relationship to Patient
Parent
Guardian
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18
Contact Number for Person completing this form
Area Code
Phone Number
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19
Appointment Request
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20
Date/Time Completed
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21
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Covid19-Antigen Test
The Antigen test identifies an active infection. Results from an FDA-authorized rapid antigen test are available in 15 minutes.
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Covid-Antibody Test
This test will tell a person if they have antibodies to the virus and to identify individuals who have had symptoms of COVID-19 or have been exposed more than 4 weeks ago and recovered.
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