• This form is for PCR Testing only

     

    Although our partner lab tries to turnaround test results in 24-72 hours, due to  the overwhelming volume of test specimens being received, test results may not be available for up to a week, or in some instances slightly longer.     

     

    Please note, beginning January 1, 2022 we will be charging a $50 admin fee due at the time of your appointment.

     

    PCR test collection available at the following locations: 

     

    Location Address Availability
    ahma Rx NYC

    2381 Frederick Douglass Blvd, New York, NY 10027

    Walk-ins Mon/Tue 11am - 4 pm or by appointment - see below
    ahma Rx Elmsford 35 Valley Ave, Elmsford, NY 10523 By appointment only - see below
    ahma Rx Garfield 85 Outwater Lane, Garfield, NJ 07026 By appointment only - see below

    For information about the PCR Test see: Fact Sheet

  • Patient Information

     
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  • Insurance Information

    Please provide information for your Medical Insurance

  • Appointment

     
  • I, the above-mentioned patient or their parent or guardian, have been provided information regarding the COVID-19 RT-PCR Test. By signing this COVID-19 PCR Request Form, I hereby agree and confirm that the information provided in this request form is true and complete. I authorize ahma Rx to forward the related information to appropriate labs and/or governmental agencies. I also agree that my clinical data and test results can be investigated and used by healthcare facilities and professionals for further scientific research. If I test positive, I agree to adhere to the current government guidelines relating to the COVID-19.

    I authorize the release to my insurance carrier of any medical information necessary to process this claim, and I authorize payment of medical benefits directly to Prophase Diagnostics.

    I understand that if I do not have insurance, I will be billed directly by Prophase Diagnostics. I also authorize release of my results to my doctor utilizing all methods of transmission according to HIPAA regulations. Deidentified patient data may be used for R&D purposes.

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