I hereby authorize and direct the above insurance company to pay benefits due in accordance with the terms of my policy payable to Malibu Medical Corporation, 23661 Pacific Coast Highway Malibu, CA 90265
●I agree to pay all medical expenses not covered by the above named policy.
●I authorize Malibu Medical to release any information needed by the insurance company regarding this claim.
●I understand and agree that it is my responsibility to verify that Malibu Medical is an approved provider for my specific insurance. If preauthorization or provider verification was not obtained, I understand and acknowledge that I am fully responsible for the bill.
●I understand and agree that if it should become necessary for Malibu Medical to pursue collections of my account through a third party, I will be liable for any and all costs associated with the collection process.
●I request payment of insurance benefits be paid directly to the physician listed on the claim.
CERTIFICATION OF NO COVERAGE
I do not have health care coverage such as individual, employer-sponsored, Medicare or Medicaid coverage.
Therefore, I affirm and attest the above patient qualifies as uninsured according to the COVID-19 Uninsured Program in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136).
COVID-19 Testing : Informed ConsentPlease carefully read and sign the following Informed Consent:a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, anterior nares swab or blood draw, as ordered by an authorized medical provider or public health official.b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.c. 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.d. 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.e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
I understand that even if I pay to expedite my test the result return time is not be guaranteed. I understand that I will only be reimbursed to the base PCR price of $125, not for the total price of the test.
I understand that result return times are not guaranteed and that all laboratory results are generated by 3rd party vendors which malibu medical corp has no control over.