A.L.M.S. CHC COVID19 Testing

Name

First Name Last Name

Date of Birth

Gender

Male Female

Mobile Phone Number

Please enter a valid phone number.

Email Address

example@example.com

SSN, or Driver's License number, or picture ID, and state of residence

Take Photo of your Drivers License or picture ID

Date of service for professional, institutional outpatient services (COVID Testing):

Have you been hospitalized in the last 90 days? (If no go to the next question. If yes, what date were you discharged from the hospital):

Yes No

Have you been exposed to anyone with suspected or known diagnosis to COVID19 in the last 2 weeks?

Yes No Not sure

If yes to the previous question, what date were you discharged from the hospital?

Have you been fully vaccinated?

Yes No

Patient Address/Facility Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Patient Account Number (Optional)

Race/Ethnicity (Optional)

Do you currently have Health Insurance?

Yes No

Take a picture of the FRONT of your insurance card:

Take a picture of the BACK of your insurance card:

DISCLAIMER

I hereby release, waive, discharge, covenant not to sue, and to hold harmless for any and all purposes Company and their healthcare staff, members, shareholders, officers, servants, agents, volunteers, or employees (herein referred to as “indemnitees”) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney fees and expenses, that may be sustained by me while participating in Testing, while traveling to and from the Testing, or while on the premises owned, leased or occupied by Indemnitees.
I am fully aware that the Testing provided by Company may involve COVID-19 tests that have not gone through a full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending such processing and that the results could produce false positives or false negatives or be administered in a way that otherwise produces inaccurate results, or they are laboratory developed and shown similar performance to EUA authorized reagents. This test has been validated in accordance with the FDA guidance document (policy for diagnostics testing in laboratories certified to perform high complexity testing under CLIA prior to emergency use authorization for coronavirus disease-2019 during the public health emergency) issued on February 29th, 2020. I am also fully aware that the Company is not providing medical care or giving a medical diagnosis with Testing and that I should consult my doctor as to the results of Testing.
I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the organization which has arranged for the testing, (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up and contract tracing). Protected heath information will not be reused or disclosed by Company to any person or entity other than the above, except as required by law.
By signing below, I am agreeing to voluntarily testing. In signing this agreement, I acknowledge and represent that I have read it, understand it, and sign it voluntarily.

I agree to the terms and conditions

Signature

Clear

DateTime

All testing will be done on a first come first serve basis on site at:

A.L.M.S. Community Health Center, Inc.

2100 Virginia Street - Suite F

Grand Prairie, Texas 75051

214.862.5756

Online registration must be complete prior to testing for all participants Our 1st testing date is set to start promptly at 10:00am on Saturday, October 2, 2021.

More dates will be scheduled on an as needed basis.