Malibu Medical Consent

Malibu Medical Group COVID CONSENT
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First Name *
Last Name *
Date of Birth* *

Month Day Year
Email *
example@example.com
Gender *
MOBILE Phone Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have Health Insurance? *

Yes No
Insurance Information
Insurance Company Name
Member ID or Subscriber ID
Group Number
If you do not have a group number enter the plan type(HMO, PPO, Medicare, etc.)
Name of the Insured Person

First Name Last Name
Relationship to the Insured person
Insurance Card Front and Back Photo

Please upload photos of the front and back of your insurance card
Cancel of
Authorization To Bill Insurance
I hereby authorize and direct the above insurance company to pay benefits due in accordance with the terms of my policy payable to Malibu Medical Corporation, 23661 Pacific Coast Highway Malibu, CA 90265

●I agree to pay all medical expenses not covered by the above named policy.

●I authorize Malibu Medical to release any information needed by the insurance company regarding this claim.

●I understand and agree that it is my responsibility to verify that Malibu Medical is an approved provider for my specific insurance. If preauthorization or provider verification was not obtained, I understand and acknowledge that I am fully responsible for the bill.

●I understand and agree that if it should become necessary for Malibu Medical to pursue collections of my account through a third party, I will be liable for any and all costs associated with the collection process.

●I request payment of insurance benefits be paid directly to the physician listed on the claim.
Signature

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COVID ATTESTATION OF UNINSURED PATIENT

Please complete the following information if you are currently uninsured
Date of Appointment / Test

Month Day Year
Date
Patient Name

First Name Last Name
Patient Date of Birth

Month Day Year
You must provide one of the following identifiers

Social Security Number OR Driver License information
Social Security Number
OR
Drivers' License #
State
CERTIFICATION OF NO COVERAGE

I do not have health care coverage such as individual, employer-sponsored, Medicare or Medicaid coverage.

Therefore, I affirm and attest the above patient qualifies as uninsured according to the COVID-19 Uninsured Program in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136).
Signature of Patient/Legal Guardian

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FULL LEGAL NAME

First Name Last Name
Relationship to Patient

Self Guardian

Informed Consent
COVID-19 Testing : Informed Consent
Please carefully read and sign the following Informed Consent:
a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, anterior nares swab or blood draw, as ordered by an authorized medical provider or public health official.
b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
c. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
d. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

Financial Policy:

I understand that even if I pay to expedite my test the result return time is not be guaranteed. I understand that I will only be reimbursed to the base PCR price of $125, not for the total price of the test.

I understand that result return times are not guaranteed and that all laboratory results are generated by 3rd party vendors which malibu medical corp has no control over.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19. *

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Malibu Medical Group COVID CONSENT

Insurance Information

Authorization To Bill Insurance

COVID ATTESTATION OF UNINSURED PATIENT

You must provide one of the following identifiers

OR

Informed Consent

COVID Symptom Check