• COVID-19 Testing Consent Form

  • TESTING SITE IS A DRIVE-THRU SERVICE. PLEASE GO TO THE BACK OF THE CLINIC AND PARK BEHIND DOOR 101.

  • CONTACT INFORMATION

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  • MEDICAL INSURANCE

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  • COVID-19 Testing

    Patient Attestation for No Insurance

     

    I, attest that I am uninsured and/or do not have a government ID.

    • I understand that signing this document while concealing insurance ownership constitutes fraud and is punishable by law.
    • I hereby acknowledge and understand that as a condition of receiving a COVID-19 Test through GloFusion Clinic, I must submit the below referenced information under the COVID-19 Uninsured Claims Program for reimbursement to GloFusion Clinic.
    • At the time of signing this form, I do not currently have insurance and have not paid a cash price for the test to be performed.

    By typing my name below, this electronic signature I attest that all written information on this attestation is fully true and accurate to the best of my knowledge.  


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  • INFORMED CONSENT FOR FREE COVID-19 TESTING FOR THE INSURED AND UNINSURED

    Please read the informed consent carefully.
  • I, authorize GloFusion Clinic to conduct collection for free or Rapid COVID-19 testing through a nasopharyngeal swab or finger stick.  Free testing may take up to 3 business days to get the results.

    • I acknowledge that a positive test result is an indication that I must continue to self-isolate for 14 days to avoid infecting others.
    • I understand that the COVID-19 testing is FREE for the uninsured under the patient care act.
    • I understand that if I do have health insurance coverage, my COVID-19 testing will be billed to my insurance provider above or insurance provided to GloFusion Clinic by the patient care act.
    • I understand that there are no co-payments and deductibles for the COVID-19 testing since it’s covered by my insurance provider.
    • I understand that GloFusion Clinic is not acting as my Primary Care Provider if I am not an existing patient or a new registered patient. Testing does not replace treatment by my medical provider.
    • I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my Primary Care Provider if I have questions or concerns, or if my condition worsens. I may also choose to register with GloFusion Clinic to be my Primary Care Provider.
    • I understand that, as with any medical test, there is the potential for false positive or false negative test results.
  • Rapid COVID-19 Testing

    Informed Consent for Rapid COVID-19 Antigen Test. Please read the informed consent carefully.
  • Rapid Antigen Test - $90 per person

    A nasal swab is performed to collect specimen to perform the test. Results are obtained in 10 minutes.

    • I will have a rapid Covid-19 test performed at GLOFUSION CLINIC.
    • A positive test is considered diagnostic, and a confirmatory testing will be performed and sent to the lab.
    • In cases where symptoms are strongly suggestive of Covid-19, a confirmatory test may be sent to Lab for confirmatory testing. This may take several days to result. I will be notified by phone, text, or email when my confirmatory test results are received.
    • By law, the Georgia Department of State Health Services (DSHS) will be notified that I was tested, and what the test results are.
    • In addition, I have been shown a copy of the instructions of what I have to do following testing, I have read those discharge instructions thoroughly, and I agree to comply with those instructions. I agree to self-quarantine until I am cleared.
    • I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, plasma or other recommended collection procedures.
    • I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.
    • I understand that Rapid COVID-19 testing is available for cash, debit/credit or flexible spending cards only and my insurance will NOT be billed for Rapid COVID-19 test. No refund.
  • I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and payment options. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to test for COVID-19.

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  • Payment

  • prev next ( X )
    COVID-19 Rapid Antigen Test A nasal swab is performed to collect specimen to perform the test. Results are obtained in 10 minutes.
    $ 90.00
       
    COVID-19 PCR Test A nasopharyngeal swab is performed to collect specimen to perform the test. No cost testing may take up to 3 business days to get the results.
    $ 125.00
       
    Total
    $ 0.00

    Credit Card

  • Confirmation

  • Dear Applicant,

    Thank you for completing your COVID-19 testing consent form.

    When you arrive to the drive thru at GloFusion Clinic, please have the following ready to give to the clinical technician:

    • Driver's license/Picture id
    • Insurance card, and
    • Form of payment (cash or debit/credit card for Rapid COVID-19 testing).

    CHECK FOR RESULTS, Follow or copy the link below

    https://pathgroup.luminatehealth.com/

    After signing up for the MyResults account, you will receive an email when your lab test results are ready to view in the portal. If you cannot locate results for a COVID-19 test after three (3) days, please contact the Lab at 888-474-5227 before contacting the office.

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