Uninsured Individual Attestation
With sound mind and clear intent, I am representing that I am an Uninsured Individual with full knowledge that the cost of this COVID-19 testing will be paid for with funds from the Federal Health Resources & Services (HRSA) COVID-19 Uninsured Program. | understand that falsely representing that I am an Uninsured Individual is a violation of the law and may result in criminal and/or civil legal actions against me.
By signing and dating below, I attest as follows:
1. As of the date of service, I am an Uninsured Individual and not enrolled in a Federal
health care program; or 2. As of the date of service, I am an Uninsured Individual and not enrolled in a group health plan or health insurance coverage offered by a health insurance issuer in a group or individual market.