Medlab, Walk-In Consent Form

Medlab, Walk-In Consent Form

COVID-19 PCR Testing Appointment and Consent Form
Appointment
Who is the test for?

Myself Child/Dependent My Patient
Patient Name (individual to be tested) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female Other
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Were you sent by a physician's office?

Yes No
Prescribing Physician Office
Other Office
Payment *

Credit Card Insurance
Insurance Payer
Other Payer
Policy Number
Social Security Number
Do you currently have any of the following symptoms?

Cough Sore Throat Fever Shortness of Breath Loss of Smell or Taste Headache
Have you recently been exposed to anyone with COVID-19?

Suspected exposure Known exposure
Consent to Bill Insurance

I authorize Medlab to submit payment claim, for laboratory services rendered, to my insurance provider. I understand I am responsible for payment of any denied claims, deductibles, and co-insurance charges. If my health plan providing medical benefits makes payment for laboratory service to me, I understand that I am responsible for making the payment to the laboratory for services rendered.
Consent to Bill HRSA

I do not currently have active health insurance, and authorize Medlab to submit payment claims, for COVID testing services, to the Health Resources & Services Administration under the Cares Act.
Parent or guardian name, if other than individual to be tested

First Name Last Name
Patient/Parent/Guardian Signature. By signing here, I give Medlab consent to collect specimen and perform COVID019 testing *

Clear
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