As part of the FFCRA, PPHCEA and CARES Act, (the "Act") the U.S. Department of Health and Human Services (HHS), will provide claims reimbursement to health care providers for testing uninsured individuals for COVID-19 and treating uninsured individuals with a COVID-19 diagnosis on or after February 4, 2020.
Therefore, kindly read the following and sign at the bottom where indicated.
I certify by my signature below that, at the time these COVID-19 testing services are rendered, I am uninsured, having no insurance coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program, and I am aware of no other payer that will reimburse Northshore Clinical Labs for my COVID-19 testing. If it is determined, however, that my statement is false, and Northshore Clinical Labs has relied upon my statement to request reimbursement under the Act, I agree to be personally liable to Northshore Clinical Labs for the full amount of Northshore Clinical Labs’ liability under the Act, and any other applicable federal or state laws or regulations. I understand that in addition to the foregoing, I may be subject to criminal, civil, or administrative liability under other state or federal laws or regulations for providing this statement falsely. In the event it is determined that you do hold insurance coverage, or did hold insurance coverage at the time of testing, Northshore Clinical Labs reserves the right to seek reimbursement through that coverage.