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  • COVID-19 Testing @ ILP

    30675 Stephenson Hwy. Madison Heights MI 48071

    248-619-4372 

    **WE ARE MOVING! STARTING, 1/23/23 OUR NEW ADDRESS FOR TESTING IS 30675 STEPHENSON HWY. MADISON HEIGHTS, 48071**

     

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  • 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

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  • 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

  •  Recipient Name:        
    Recipient Address:                         
    Email:      Phone:         
    Fax:    

  • 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:    .
    • 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).

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