Western University

HIPAA Release
By signing in the box below I am stating the following: "I authorize and request that my COVID Test results be disclosed to, and used by, appropriate WesternU officials, including but not limited to appropriate officials in the WesternU’s Student Employee Health Office, in order to encourage a safe campus, workplace, and learning environment, and to enhance the safety of WesternU’s students, employees, and visitors"

This HIPAA Release is valid for 1 year from the date of submission of this form.
Tested Individual's Name *

First Name Last Name
Birth Day *

Month Day Year
Gender *

Female Male Other
Signature

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Travel and Exposure
Are you seeking a test to prevent the possible spread of COVID-19 for future travel, work or recreation (According to CDC Guidelines)? *

Yes No
Are you seeking a test to prevent the possible spread of COVID-19 after being at a place where social distancing was not possible? *

Yes No

Do you have Insurance? *

Yes No
Insurance Company. (Please select closest one) *
If other please enter here
Insurance Group Number *
Insurance Member ID *
Please upload Front Insurance Card if Applicable *
Please upload Back of Insurance Card if Applicable *
Please upload the Front of the ID Card - Drivers License, WesternU Student ID or Employee ID *

By signing in the box below I am stating the following: I understand that my personal information and test results will be shared with my state’s Department of Public Health. I understand if the person being tested is under 18 years old, a parent or guardian must be present at testing and consent to the testing. I understand that the results of the COVID-19 rt-PCR nasal swab test should be correlated with clinical symptoms and discussed with my medical professional. I understand that a negative result does not exclude the possibility of infection, however, it just indicates that the collected sample is negative. I consent to being tested by Trilab Health (CLIA ID:14D2096036) and confirm that I am at least eighteen years of age or signing for a minor under the age of eighteen. I acknowledge that I have the authority to assign to Trilab the right to bill and collect from any health insurance plan that I may have. I assign the right for Trilab to bill and collect from my health insurance plan that covers any physicians, caregivers, or other providers of services who are not employed by Trilab and whose services will be billed separately for all services provided.
Signature *

Clear
Should be Empty:

HIPAA Release