To make a change to your appointment time:1. Scroll down to the Appointment Calendar. 2. Select a new appointment time slot.3. Scroll to the bottom of the form and press submit.
To cancel your appointment:1. Scroll down to the Appointment Calendar. 2. Deselect your current appointment time slot.3. Scroll to the bottom of the form and press submit.
We are unable to provide testing services to children under 6 months of age.
Because you are not experiencing symptoms, have not been recently exposed to anyone diagnosed with COVID-19, and do not have any risk factors, you are required to pay for your COVID-19 test.
Please note: Appointments not canceled within 24 hr of the appointment date and time will incur a $15 fee to cover administrative fees.
Please complete below and attach copy of insurance card to this form.
A social security number, state of residence, and driver's license number/state identification number is needed to verify patient eligibility. If this information is not submitted, you will need to attest that you attempted to capture this information before submitting a claim and that the patient did not have this information at the time of service. Claims submitted without the necessary information may take longer to verify and will be billed to the client at $100 per test.
While COVID-19 testing is covered under the CARES Act, testing for Influenza A and B are not. As a result, patients with insurance will have influenza testing billed to their insurance and will be responsible for any co-pays or coinsurance due from the testing.
I authorize the laboratory to provide my health plan with the information on this form and other information provided by my health care provider if necessary for reimbursement. I understand that the laboratory may seek prior authorization for testing from my health plan on my behalf. I also authorize all benefits from the plan to be payable directly to the laboratory, and I agree to remit to the laboratory any payment for these services made directly to me. I understand that the laboratory may be an out-of-network provider for my health plan and that I am responsible for all amounts not reimbursed by my health plan. I hereby designate the laboratory as my Authorized Representative, as provided under ERISA, 29 C.F.R § 2560.5031 (b)(4), and/or as my Attorney in Fact, for the purpose of pursuing administrative appeals to which I am entitled and, if the laboratory deems it appropriate, any legal and/or equitable claims that I could bring against my health plan, and/or its administrators, with respect to their handling or resolution of my insurance claim.
I understand that in certain circumstances, the laboratory is required to report test data to relevant state public health agencies.
I agree that my de-identified specimen and test data (where information that could link me to the specimen or data has been removed, making it unlikely that I could be identified) may be retained, used and disclosed for research and/or to help develop products or services, in compliance with applicable laws.
I understand that I will not receive any royalties, payments, benefits or rights from any resulting products or discoveries, and that if I do not want my de-identified specimen and test data to be retained, used or disclosed for research or product development purposes I should call Customer Service at 1-855-776-9436.