School Covid Swab Form for new patient WITH Day of Testing Testing Location AND Time of Testing in same field 2

School Covid Swab Form 2
Patient Information
First*
Middle
Last*
School grade*
Day and Time of Testing*
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Street Name*
Apartment # (If applicable)
City*
State*
ZIP Code*
Home Phone
Cell Phone*
Email Address*
example@example.com
Insurance Information

Primary Insurance
Insurance Carrier*
If UnitedHealthcare, please specify which plan.
Primary Subscriber's Name:*
Date of Birth*

MonthDayYear
Date
Patients Relationship to Subscriber*

SelfSpouseChildParentOther
Policy Number*
Group Number*
Secondary Insurance
Insurance Carrier:
If UnitedHealthcare, please specify which plan.
Primary Subscriber's Name
Date of Birth

MonthDayYear
Date
Patients Relationship to Subscriber

SelfParentChildSpouseOther
Policy Number
Group Number
I allow Hebrew Academy of Long Beach to receive test results.*

YESNO
Assignment of Benefits and Financial Waiver
I hereby request that payment of authorized benefits be made on my behalf for the duration on any care to Rapid Response Medical Care for any services provided by Rapid Response Medical Care. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents or to any private insurance company any information needed to determine these benefits or the benefits payable for related services.

I understand and agree that I am responsible for the following expenses: any services my insurance deems "non-covered", all coinsurance and/or copayment amounts, all deductibles. Any amount that exceeds benefit limits under my insurance plan and any amount my insurance plan deems not covered because I was not insured on the date of service.

I understand that it is my responsibility to understand my insurance benefits and plan coverage.
Patient/Legal Representative Signature*

Clear
Date*

MonthDayYear
Date
PATIENT HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); • Obtaining payment from third-party payers (e.g. my insurance company); • The day-to-day healthcare operations of your practice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Signed thisex: 19th* day of ex. February* , ex: 2020*
Name*

First NameLast Name
Signature*

Clear
Relationship to patient*
Rapid Reponse Medical Care 600 Franklin Ave. Franklin Square, NY 11010
Should be Empty:

School Covid Swab Form 2

Patient Information

Insurance Information

Secondary Insurance

Assignment of Benefits and Financial Waiver

PATIENT HIPAA CONSENT FORM