ILP Covid Registration

**As of May 12th, 2023, ILP will no longer be providing COVID-19 testing. Please contact your Primary Care Physician or nearest Urgent Care.**

30675 Stephenson Hwy. Madison Heights MI 48071

248-619-4372
Reason for seeking test:*

Travel (NOT COVERED by Insurance/ $100 Cash or Credit due at time of testing)
Appointment*

Requesting AppointmentSpecial Appointment Request
Choose Employer/Group Registration Code*
Today's Date*

MonthDayYear
Date
Royal Oak or Employer/Group Location

Royal Oak (26154 Woodward Ave)Employer/Group Location
Date of Testing*

MonthDayYear
Date
Madison Heights: Choose Your Appointment DATE/TIME Request
Appointments will be confirmed via email by our Covid staff. If you need to make changes to your appointment call #248-619-4372 Do Not Make Another Appointment.

SCMC Surgical patients please visit SCMC website TO REGISTER: scroll to bottom of page under "quick links" and click "covid-19 testing". Alternatively, you can visit the form directly: https://hipaa.jotform.com/203075712331041

~ Thank you
Personal Information
Full Legal Name *

Legal First NameMiddle NameLegal Last Name
Date of Birth:*

MonthDayYear
Date
Gender*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code / Postal CodeCountry
Phone Number*
Courtesy calls on positive results will be made to the above #
Email*

Confirmation EmailResults released to above email
Form of Payment*

Self-Pay ($100 Cash or Credit Card at the time of the test)
Insurance Information
Insurance Name*
Insurance Name or N/A if Self Pay
Policy ID/Policy #*
Policy ID or N/A if Self Pay
Group #
Name of Insured:*
Relationship:
Driver's License / State ID Card / Passport

Required for registration & and any changes (if unable to upload please provide at appointment)
Cancelof
PASSPORT #
Passport # for International Travel
Insurance ID Front

Required for registration & and insurance changes (if unable to upload please provide at appointment)
Cancelof
Insurance ID Back

Required for registration & and insurance changes (if unable to upload please provide at appointment)
Cancelof
Symptoms:
Muscle or body achesDiarrheaHeadacheShortness of breathCoughChillsNew loss of taste or smellSore throatCongestion/Runny noseFatigueFeverNONENausea/VomitingOther
Have you been
ExposedVaccinatedHaving symptoms aboveOther
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:*

Self/Parent or Guardian/SpouseOther (Provide recipient information below)
Recipient Name:   First Name   Last Name
Recipient Address:   Street Address    Address Line 2   City       State   Zip
Email:   Email    Phone:      Phone Number
Fax: Fax Number
Disclosure Format:*

U.S. Mail - Paper FormatFax (healthcare provider/facility)E-mailPick 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. Or upon the occurrence of the following date/event/condition:   Fill .
• 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.
• I may request that certain information about me not be released to third parties. Information that I wish not be shared is as follows:          .
• Third parties I wish not to share this information with include:      .
• 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).
Patient or Authorized Representative Signature*

Clear
Print Name*

First NameLast NameSuffix
Relationship to Patient*
Today's Date*

MonthDayYear
Date
Thank You!

Your submission has been received.

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**As of May 12th, 2023, ILP will no longer be providing COVID-19 testing. Please contact your Primary Care Physician or nearest Urgent Care.**

30675 Stephenson Hwy. Madison Heights MI 48071

248-619-4372

Personal Information

Insurance Information

Symptoms:

Have you been

Patient Authorization to Release Health Information

Thank You!

As of May 12th, 2023, ILP will no longer be providing COVID-19 testing. Please contact your Primary Care Physician or nearest Urgent Care.