Orlando - Jane Screening Insurance

FG Health

3295 Oxford Drive

Kissimmee, Florida 34746

Phone: (689) 888-0456
FG Health Insurance/Uninsured form

Please note: for the uninsured (if you do not have health insurance) you can schedule an appointment using this form. If you do have health insurance, please fill this form. Jane will check for benefits and contact you. Please wait for a call from Jane to let you know if you have benefits prior to arriving at our site.
How did you hear about us? *

Friend/Family Google Physician
First Name *
Last Name *
Full Name
Gender *

Male Female No Response
Date of Birth (MM/DD/YYYY) *

Month Day Year
Date
Age
Home Phone *
Mobile Phone *
E-mail *

Confirmation Email
Florida Address

Your home address if US resident, or where you stayed while visiting
Street Address *
City *
State *
Zip *
County *

Lake Orange Osceola Polk Seminole Volusia
Is this your home address *

Yes No
Home Address
Street Address 2 *
City 2 *
State / Province
Zip 2 *
County 2
Country *
Passport Number
Home Address
Medical Screen

Please list the symptoms that you have been having and for how long:

	Symptom	Number of Days
Cough (Tos)
Cold (Frio)
Fever (Fiebre)
Body Aches (Dolor de cuerpo)
Nausea (Náusea)
Fatigue (Fatiga)
Sneezing (Estornudos)
Runny/Stuffy Nose (Congestión nasal)
Shortness of breath (Dificultad para respirar)

Any additional symptoms and duration
Insurance Information
Insurance *

I DO have health insurance I do NOT have health insurance
Insurance Company *
Subscriber ID# *
Subscriber Name *
Relationship to Patient *
Provide a picture of your Photo ID *

Browse Files

Cancel of
Provide a picture of the front of your insurance card *

Browse Files

Cancel of
Provide a picture of the back of your insurance card *

Browse Files

Cancel of
Assignment of Benefits

I request that payment of authorized health care benefits be made on my behalf to FG Health Group LLC for any services provided to me by FG Health Group LLC. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related services. I acknowledge that I have received and understand FG Health Group LLC privacy policy and Patient Bill of Rights. I understand that I am financially responsible for any charges not covered by my health care benefits. I understand that it is my responsibility to notify FG Health Group LLC of any new insurance or changes in my health care coverage. If a change in my health care coverage is not reported prior to the services being provided, I understand that I am financially responsible for any charges if payment is denied. Not all services and/or equipment may be covered or paid for by the Responsible Party’s (primary policy holder’s) private insurance. The Responsible Party agrees to pay all deductibles, co-pay, non-covered services/equipment, and any portion of covered services not paid in full by private insurance, when applicable. The Responsible Party understands that payments are due immediately upon presentation of the bill. The Responsible Party(ies) agree that FG Health Group LLC may use any information provided herein for collection purposes.

By signing below, I agree that this Contract shall be governed by the laws of the State of Florida, without regard to the principles of conflicts of laws. The venue for any disputes will be exclusively with the appropriate court in Osceola County Florida.
Patient Consent

Please carefully read the following:

1. I authorize this COVID-19 testing laboratory to conduct collection and testing for COVID-19 through a swab or blood draw.

2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

3. 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.

4. 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.

5. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test results. I understand and agree that all charges are refundable up to 24 hours before my appointment. Charges are non refundable within 24 hours of my appointment. No shows will be charged the full amount. This is a cash service. We do not accept Medicaid or Medicare payment for this service. We do not offer COVID medical or travel guidance. For medical questions: FDOH Covid DOH Hotline: 1.866.779.6121 For travel requirement and policies please contact your airline.
*
Today's Date

Month Day Year
Signature *

Clear
Test Type *

PCR Antigen
Collection Date *

Month Day Year
Date
Collection Time *

: Hour Minutes AM/PM Option
Collection Date&Time *
Collected Specimen Type *
PCR Results *
Antigen Results *
Antibody Results IGG *
Antibody Results IGM *
Overall Test Results *
Status
Sticker Info:

{fullName} {gender} {dateOf27} {age} - I/B

{phone}

{email8}

{passportNumber}

{date} {testType}
Should be Empty:

FG Health Insurance/Uninsured form

Florida Address

Home Address

Medical Screen

Insurance Information