I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of billing of at home covid test(s) requested. I understand that it is not possible to predict all possible side effects or complications associated with receiving test(s) On behalf of myself, my heirs and personal representatives. I hereby release and hold harmless Valley Medical Pharmacy, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the test(s) listed above. I authorize Valley Medical Pharmacy as applicable, to release my medical or other information to my healthcare professionals,Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf Valley Medical Pharmacy as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including co-pays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, upon receipt of such invoice.