NCMG COVID-19 Test Registration

COVID-19 Test Registration

North Clark Medical Group (Referred as The Practice from here on)
- Drive-through COVID-19 testing is available, appointment required to reduce your wait time.
- Face mask is required for COVID-19 testing.
- For healthcare workers, COVID-19 testing is available at our Jeffersonville location with minimum wait time.
- For questions regarding COVID-19, please call on (812) 288-2488.
How did you hear about us?

Primary Care ProviderOther
Primary Care Provider Name
Primary Care Provider Phone
Please Select a Location*

1802 E 10th Street, Jeffersonville, IN 47130 (09:00 a.m. - 04:00 p.m. Mon-Sat)2100 Market Street, Charlestown, IN 47111 (09:00 a.m. - 04:00 p.m. Mon-Fri)
Do you have a fever or have you felt hot or feverish in the last two days? If so, what was your temperature?*
Please select your symptoms*

Have contact with someone who was diagnosed with COVID-19 or live in or visit a place where COVID-19 is spreading?Are you having shortness of breath?Do you have a cough?Runny or stuffy noseSore throatMuscle achesBody aches or headachesFatigue or malaiseNausea, vomiting or diarrheaLoss of taste or smellNo Symptoms
Preferred Appointment Date*

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Appointment Time (9:00 AM - 4:00 PM)*

:HourMinutesAM/PM Option
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Your Information
Name*

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Address*

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Date of Birth*

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Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Agree to Text and E-mail Messages*

I agree to receive text messages and e-mails from the practice
Payment Information
Payment Method

Medical InsuranceUninsured (No problem, we can still take care of you)
Uninsured*

I certify that I do not have any kind of health insurance or other source for paying for this test.
Insurance Information
Do you have insurance? Do you want us to bill your insurance? We can bill your insurance company - it may be Out of network billing. If we get reimbursed from your insurance company, we will reimburse you the money you paid back to your account.

We may have to bill as out of network if your insurance provider is not within our network.
Primary Insured Name*

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Street Address

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CityState / Province

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Primary Insured Phone Number*

Area CodePhone Number
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example@example.com
The charge on your credit card statement will show as North Clark Medical Group, LLC.

SSN / TIN*
Your Drivers License / State Approved ID and Insurance Card (Front and Back)*

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Take Photo of Your Drivers License or State Approved ID (Front)*
Take Photo of Your Drivers License or State Approved ID (Back)*
Take Photo of Your Insurance Card (Front)*
Take Photo of Your Insurance Card (Back)*
Attach Image of Drivers License or State Approved ID (Front and Back)*

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COVID-19 Patient Screening Consent Form
I authorize The Practice to collect my blood with a finger stick and/or a nasopharyngeal swab for COVID-19 screening.

I acknowledge the test is not reviewed by the U.S. Food & Drug Administration (FDA). COVID-19 antibody test is performed at a CLIA certified HIGH COMPLEXITY lab authorized to perform such tests. I authorize lab to perform COVID-19 antibody test on my specimen and communicate results.

I understand the processing of the specimen and results may take upto 2 business days.

I am the parent or legal guardian (if the patient is a minor or dependent) of the patient named above

By selecting checking the box next to “I have read and agree to the Consent Form” field when making an online appointment, I acknowledge that I have read, understand, agree, certify, and/or authorize the information. I further agree to hold harmless North Clark Medical Group, LLC, its officers, directors, employees, contractors and agents against all liability, obligations, claims, loss and expense arising out of any liability.
Read and Accept*

I have read and agree to the North Clark Medical Group COVID-19 PatientScreening Consent Form
COVID-19 Testing Disclosure Form
Testing

The Practice provides COVID-19 screenings antibody test specimen collection at several different center in Indiana, Kentucky, Georgia, Ohio, Mississippi, and Texas at specified test sample collection sites. Test samples conducted at these sites are transported

Testing schedule is Monday-Saturday from 9:00 AM to 4:00 PM.

The test fee is $119.00, payable by cash or credit card. Patients with positive test results will need follow-up with their primary care physician or will be referred to a local Clinic for further management. You should be able to receive reimbursement for COVID-19 testing from your health insurance company by sending the claim form for the test that we will be glad to provide. We may accept any insurance as out of network provider. All COVID-19 visits are provided by our providers as telemedicine visit.

Drive-through testing must be conducted in an automobile. Other means of transportation, including walk-up and bicycles is strictly not permitted. Everyone must have face mask on. Please advise at time of appointment/registration if you will have someone drive you to the location. Please stay in your vehicle during test procedure. Test recipient must present a driver’s license or state issued identification card to clinician. All paperwork must be completed online or via phone/email prior to arrival at the facility. Children are eligible for testing. All minors under 18 must be accompanied by a parent or guardian. The parent or guardian must have state issued identification.

Testing Requirements

In order to be tested, you MUST:
1. Have or had symptoms consistent with COVID-19.
2. Been exposed to someone with COVID-19
3. Have a COVID-19 test prescription from your healthcare provider
4. Read and accept the consent form
5. Schedule an appointment on our website
Schedule Your Appointment

Go online to our website and complete the registration information or call us. For healthcare worker, We provide special accommodations, let us know if you are a healthcare worker.

Testing appointments will be assessed by order of following priority:

Priority Testing: High-risk patients will be assessed and tested in the following order:
1) Priority 1 = Highest Risk
a. Hospitalized Patients
b. Healthcare facility worker
2) Priority 2 = Identify highest risk
a. Patients in Long Term Facilities
b. Patients 65 years of age
c. Patients with underlying conditions
d. First responders
3) Priority 3 = Assist with decrease of community spread and to ensure health of essential workers
a. Critical infrastructure workers
b. Individuals who do not meet any of the above criteria but have symptoms
4) Priority 4 = No complications – wanting to be tested
a. Individuals without symptoms

FDA mandated COVID-19 IgM / IgG Antibody Testing Disclosure
- This test has not been reviewed by the U.S. Food and Drug Administration (FDA). The Tests can only be processed by CLIA certified high complexity labs.
- Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule out infection in these individuals.
- Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.
- Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
- The antibody test does not identify people plasma donors for treatment of patients suffering from COVID-19 infection.
Read and accept:*

I have read and accept the Testing Disclosure Form
Mediation and Dispute Resolution Agreement
Mediation and Dispute Resolution Agreement Your care is important to us, and we feel it is vital to your treatment that we communicate openly and honestly. As such, we request that you: Ask questions and participate in your care, be honest about your history, symptoms, and other important health information, prepare for and keep scheduled visits, and be respectful to our office staff and healthcare providers.

In exchange, we agree that we will: Explain diagnosis, treatment recommendations, and outcomes in an easy-to-understand way, listen to your questions and help you make decisions about your care, keep discussions and records private, and determine when a referral or termination of care is appropriate.

MEDIATION As a part of our emphasis on open communication, we ask our patients to sign this mediation agreement. While we do not anticipate any issues or concerns during the course of your treatment, if any arise, you (and/or your legal counsel) and your healthcare provider (and/or their legal counsel) agree to meet with a neutral mediator and work toward a solution. Whether or not a solution is found, mediation may postpone but does not remove or block your legal rights. Importantly, you agree that any usage or inference to a "claim" will be understood and read as "potential claim" until the mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. Your signature on this page confirms that should a concern arise in any aspect of the care provided by this office, staff, and affiliated healthcare professionals, you agree to mediate first before pursuing legal action.

EXPERT WITNESSES Further, if after mediation, you still wish to pursue a court action relating to your care, your signature on this page confirms that you will use, as your expert witness(es) in your legal action, American Board of Medical Specialties board-certified medical witness(es) in the same specialty as Physician. Furthermore, you agree that the physicians who you select will be in good standing and adhere to all of the rules and guidelines of professional conduct of the American Board of Medical Specialties. As consideration for this agreement, we agree that we will adhere to these same guidelines in selecting our expert witness(es) for any court action relating to your care.
Agree by checking the box

I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.
HIPAA Release of Information Authorization Form
North Clark Medical Group herein known as the practice

I hereby authorize the practice and its affiliates, employees, and agents to release information to:
Please Select

SpouseFamilyPrimary Care ProviderInformation is NOT to be released to anyoneOther
COVID-19 test must be reported to the local Health Department per the CDC and Health Department guidelines. My or my legal dependents person health information maintained by the practice (e.g., Information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, member ID number) except the following information:
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if the practice, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Completion
I certify that the information I have provided above is accurate to the best of my knowledge.

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COVID-19 Test Registration

Your Information

Payment Information

Insurance Information

COVID-19 Patient Screening Consent Form

COVID-19 Testing Disclosure Form

Testing

Mediation and Dispute Resolution Agreement

HIPAA Release of Information Authorization Form

Completion