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.