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 authorize Malibu Medical and FLOW Labs to release any information needed by the insurance company regarding this claim.
●I request payment of insurance benefits be paid directly to the Malibu Medical Group and FLOW Labs.
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).
a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a saliva collection, nasopharyngeal swab, anterior nares swab, as ordered by an authorized medical provider or public health official.
b. I authorize my test results to be disclosed to the MUSE representatives as deemed necessary for the enforcement of public health policy and district protocol. Individuals including but not limited to; MUSE administrators, site Principal, Assistant Principals, and MUSE associated health staff. Additionally, results will 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 for ten (10) days and until symptom free.
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. I acknowledge my acceptance that the district will not accept repeat tests from samples collected on a different day as evidence of a false positive and that a negative test means that SARS-CoV-2 was not detected but could still be present.
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 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 and FLOW Laboratories
●I authorize Malibu Medical and FLOW Laboratories to release any information needed by the insurance company regarding this claim.
●I request payment of insurance benefits be paid directly to the physician listed on the claim.