TruChoice Diagnostics COVID Pre-Registration

Patient Demographic Information

TruChoice Diagnostics Pre-Registration
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
E-Mail:
example@example.com
Date of Birth

MonthDayYear
MM/DD/YYYY
Race:
Social Security Number:
000-00-0000
Gender Identification:

MaleFemaleOther
Gender:
Marital Status:
Primary Care Physician (PCP):
Medical Insurance:

YesNo
Insurance Card Holder:

SelfSpouseOther
If other than self, please provide Insurance Card Holder information:
Name:

First Name Last Name
Date of Birth:

MonthDayYear
MM/DD/YYYY
Insurance Plan Name:
Insurance ID:
Insurance Group #:

ATTENTION

YOU HAVE INDICATED YOU HAVE NO HEALTH INSURANCE

If you wish to pay out-of-pocket for your COVID-19 test, please continue to Self-Pay COVID-19 Testing Pre-Registration.

ATTENTION

You have indicated that you have no recent exposure and/or no symptoms.

Health Insurance Companies will only pay for Diagnostic COVID-19 Testing. Insurance will not cover the cost of COVID-19 testing for screening or travel purposes. All Non-Diagnostics COVID-19 Tests must be payed for out-of-pocket without insurance.

If you are not experieincing any symptoms and have not had a recent exposure to someone infected with COVID, please complete our Self-Pay Services Pre-Registration.

SELECT TEST BELOW

Test 1 COVID RAPID ANTIGEN

COVID RAPID ANTIGEN
Test 2 COVID PCR

COVID PCR
Test 3 FLU RAPID ANTIGEN

FLU RAPID ANTIGEN
Test 1

COVID RAPID ANTIGEN
Test 2

COVID PCR
Test 3

FLU RAPID ANTIGEN

Attending Provider Agreement

TruChoice Diagnostics, LLC
Consent for treatment/payment:

      This is to certify that I consent to and authorize the performance of specimen collection and analysis of the chosen laboratory panels.

      TruChoice Diagnostics, LLC cannot perform laboratory testing for patients who do not have a Primary Care Physician; A Primary Care Physician must be provided upon registration in the event that the Attending Provider who your labs are ordered under needs to reach them in regards to any critical results. I understand that the Attending Provider will not follow up with me or my Primary Care Physician regarding my lab results unless there is a critical value and it is my responsibility to obtain my results and seek interpretation, counsel, or treatment.

      I agree to take full financial responsibility for the cost of the tests that I request and that payment/insurance must be rendered prior to specimen collection.
Primary Care Physician (PCP):
Signature:

Clear
Signature Date:

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/15/03, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of the Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we mad the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of the Notice, please contact us using the information listed at the beginning of this notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations.
Treatment: We may use and disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare
operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing
activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us
written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in
effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those
described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice.
We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare
of with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or
locating) a family member, your personal representative or another person responsible for your care, of your location, your general
condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an
opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health
information based on a determination using our professional judgment disclosing only heath information that is directly relevant to the
person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make
reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar
forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written
authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
AUTHORIZATION FOR RELEASE OF INFORMATION & PAYMENT POLICY
1. I hereby authorize direct payment of surgical/medical benefits to TruChoice Diagnostics LLC and any of its affiliated providers for any services rendered.
2. I understand I am responsible for any balances not covered by my insurance.
3. I understand I am responsible for any balances not paid due to lack of providing correct and timely billing information.
4. I authorize the release of any medical information necessary for the processing of medical bill claims.
5. I authorize the release of medical information to other physicians and/or facilities involved in my health care.
6. I acknowledge I have been given a copy of the "Notice of Privacy Practices." (File available for download below)
Name:

First NameLast Name
Signature:

Clear
Signature Date:

MonthDayYear
Date
Notice of Privacy Practices Download:
Should be Empty:

	Yes	No	Duration:
Fever
Loss of Taste / Smell
Body / Muscle Aches
Stuffy / Runny Nose
Sore Throat
Nausea / Vomiting
Diarrhea
Cough
Shortness of Breath
Other

Patient Demographic Information

If other than self, please provide Insurance Card Holder information:

ATTENTION

Symptom Evaluation

ATTENTION

SELECT TEST BELOW

Attending Provider Agreement

NOTICE OF PRIVACY PRACTICES

OUR LEGAL DUTY

AUTHORIZATION FOR RELEASE OF INFORMATION & PAYMENT POLICY