Accu Reference Labs Serology (Antibody) Testing Registration

Serology (Antibody) Testing Registration
All information is kept strictly confidential and only shared as required by law.
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Are you currently in experiencing any COVID-19 symptoms?

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For the safety of our staff, you are not currently eligible for antibody testing. Please contact us after you complete your quarantine period. Thank you for understanding.
Serology C480*
Test Date

MonthDayYear
Date
Name (of person being tested)*

FIRST NAMEMiddle NamePATIENT LAST NAME
DATE OF BIRTH (M/D/Y)*

MonthDayYear
Date
Mobile Phone*
Please enter a valid phone number.
Gender*
Alternate Phone Number
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Email*

Confirmation Emailexample@example.com
Personal Address*

Street Address

Apartment No.

CityState / Province

Postal / Zip CodeCountry
Choose your Doctor*

Serology (Antibody) Testing Registration
INSURANCE INFORMATION

PLEASE CONFIRM THAT YOUR INSURANCE WILL COVER ANTIBODY TESTING. WE HAPPEN TO KNOW THAT CIGNA AND HORIZON WILL NOT COVER.
Primary Insurance Name*
Primary Insurance Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Insurance Patient ID*
Primary Group Number*
Patient Relation to Insured

Serology (Antibody) Testing Registration
HIPAA Authorization and Waiver of Liability

The undersigned has requested a COVID-19 Serology and/or other diagnostic test for the undersigned and/or the minor child of the undersigned at the Accu Reference Labs Baltimore Community testing location located at 122 Slade Ave. Baltimore, Maryland 21208 or other location (the "Baltimore Community COVID-19 Testing")

The undersigned hereby releases from any liability all of the individuals performing the testing, the STAR-K Kosher Certification, Inc., and any other entity involved in hosting the Baltimore Community COVID-19 Testing, and all of their respective officers, directors, employees and agents.

The undersigned authorizes ACCU REFERENCE MEDICAL LABS, Timonium Urgent Care, Dr. Yosef Levenbrown, Dr. Julian Jakobovits and any other healthcare provider I designate as a recipient of the protected health information referenced herein to use and disclose the protected health information described below to Jewish day schools in the Greater Baltimore area and/or my place of employment as they deem appropriate.

Effective Period: This authorization for release of information covers the period of healthcare from 8/1/2020 TO 12/31/2022.

Extent of Authorization: The undersigned authorizes the release of his/her complete health record.

This medical information may be used by the person the undersigned authorizes to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as the undersigned may direct.

The undersigned understands that the undersigned has the right to revoke this authorization, in writing, at any time. The undersigned understands that a revocation is not effective to the extent that any person or entity has already acted in reliance on this authorization or if the undersigned's authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

The undersigned understands that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
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Date

MonthDayYear
Date
If on behalf of minor child, name of child

Serology (Antibody) Testing
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Serology (Antibody) Testing Registration

All information is kept strictly confidential and only shared as required by law.

Serology (Antibody) Testing Registration

INSURANCE INFORMATION

Serology (Antibody) Testing Registration

Serology (Antibody) Testing