PCR Testing Form

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

Testing & Collection Site: *

Patient Information

Patient Name *

First Name Last Name

Date of Birth *

Date

Gender *

Cell Phone Number (to receive results) *

Please enter a valid phone number.

Email (to receive results) *

example@example.com

Address *

Street Address

Street Address Line 2

City State

Zip Code

Insurance Information

Please provide information for your Medical Insurance

Insurance Name: *

Group / Plan: *

Group #: *

Policy #: *

Payor Name:

Plan Type:

i.e. HMO, Medicaid, PPO

Please provide a picture of your medical insurance card

Appointment

ahma Rx NYC - Appointment

ahma Rx Elmsford - Appointment

ahma Rx Garfield - 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.

Signature *

Clear