Intake form &#8211; VCTR Medical Solutions

Reason for seeking test: (Required)*

Other (Required)*

Please detail what other symptoms you have.

Appointment (Required)*

Appointment

Name*

First NameLast Name

Date of Birth*

##/##/####

Gender (Required)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Form of Payment (Required)*

InsuranceSelf-Pay (Cash or Credit Card at the time of the test)

Insurance Name (Required)*

Insurance Name or N/A if Self Pay

Policy ID/Policy #(Required)*

Group# (Required)*

Name of Insured (Required)*

Relationship:(Required)*

Driver's License / State ID Card / Passport (Required)*

Required for registration & and any changes (if unable to upload please provide at appointment)

Insurance ID Front (Required)*

Required for registration & and any changes (if unable to upload please provide at appointment)

Insurance ID Back (Required)*

Required for registration & and any changes (if unable to upload please provide at appointment)

Symptoms (Required)*

Current Medical Conditions (Required)*

Credit Card Number (Required)*

Expiration Date (Required)*

Security Code (Required)*

Name as it appears on card (Required)*

Have you or anyone in your household traveled outside of your State of Residence in the past two weeks?(Required)*

YesNo

In the past two weeks have you or anyone in your household had contact with any person suspected or confirmed to have contracted Covid-19? (Required)*

YesNo

Have you had a positive Covid-19 test in the past 90 days? (Required)*

YesNo

Have you had a Covid-19 vaccination in the past 6 months? (Required)*

YesNo

Type of vaccination (Required)*

Patient Authorization to Release Health Information
I authorize the following protected health information to be released from my medical record(s) on Date of Service:

• Laboratory Reports

I request that my protected health information (PHI) from this facility to be disclosed to: *(Required)*

Self/Parent or Guardian/SpouseOther (Provide recipient information below

Disclosure Format (Required)*

U.S. Mail - Paper FormatE-mailFax (Healthcare Provider/Facility)Pick up

By signing this authorization form, I understand that:

I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management Department at the following address:

22401 Foster Winter Dr. Southfield, MI 48075

Revocation will not apply to information that has already been disclosed in response to this authorization. Unless otherwise revoked, this authorization will expire (6) months from date of signature.

My health record may include information relating to sexually transmitted disease(s) (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse.

Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by the Federal Privacy Standards.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.

I UNDERSTAND THAT I MAY INCUR FEES FOR RECEIVING COPIES OF MY MEDICAL RECORDS. FEES FOR COPIES OF MEDICAL RECORDS ARE REGULATED BY THE STATE OF MICHIGAN.

Patient Acknowledgement
I voluntarily consent to the collection and testing of my specimen. I understand that I am responsible for all co-pays,deductibles, and amounts not covered by my insurance. I assign to laboratory all insurance payment(s) made for services provided to me and direct same to represent me in any grievances or appeals process relating to the payment of these services. I consent to the release of any medical records necessary to process claim(s).

Signature

Name

First NameLast Name

Relationship to Patient (Required)*

Self/Parent or Guardian

Date

**You will receive an auto response email confirming your successful submission**

**Check-In Instructions**
STAY IN YOUR VEHICLE
Please Park in the FIRST AVAILABLE parking space (with sign)

TEXT: 248-619-4372

LAST NAME / Vehicle Make-Model-Color

Staff will come out to your vehicle

*If you are unable to text please call 248-619-4372

*Laboratory is not open to public*