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 authorize Malibu Medical and HCCL Labs to release any information needed by the insurance company regarding this claim.

●I request payment of insurance benefits be paid directly to the Malibu Medical Group and HCCL Labs.

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 Consent 

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a saliva collection, NasoPharyngeal swab, anterior nares swab, as ordered by an authorized medical provider or public health official. 

b. I authorize my test results to be disclosed to the MBUSD representatives as deemed necessary for the enforcement of public health policy and district protocol. Individuals including but not limited to; MBUSD administrators, site Principal, Vice Principals, and MBUSD associated health staff. Additionally, results will be disclosed to the county, state, or to any other governmental entity as may be required by law. 

c. I understand that under no circumstances does Malibu Medical Corp share or transfer any information, other than results to administration and CalRedie, as required by state law. 

d. 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. 

e. 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. 

f. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I acknowledge my acceptance that the district will not accept repeat tests from samples collected on a different day as evidence of a false positive and that a negative test means that SARS-CoV-2 was not detected but could still be present. 

Financial Policy: 

I understand that result return times are not guaranteed and that all laboratory results are generated by HCCL which Malibu Medical Corp has no control over. 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 and HCCL Laboratories 

●I authorize Malibu Medical and HCCL Laboratories to release any information needed by the insurance company regarding this claim. 

●I request payment of insurance benefits be paid directly to the physician listed on the claim.