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.

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.

1. I understand that this authorization will expire 30 days from this date.
2. I understand that I may revoke this authorization prior to the release of results.
3. I understand that I can refuse to sign this authorization and this refusal will not affect my ability to obtain service.
4. I may inspect or copy any information used or disclosed under this agreement.
5. I authorize the release of medical information to other physicians and/or facilities involved in my health care.
6. I understand that if the person or organization that received the information is not a healthcare provider, the information described above may be redisclosed and would no longer be protected under these regulations.

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)