COVID-19 Testing Consent Form

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
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Marital Status *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
E-mail
example@example.com
MEDICAL INSURANCE
Do you have medical insurance? *

Yes No
Insurance Company *
Member ID *
Group ID
Insured Name *
Insured Date of Birth *

Month Day Year
Date
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.
Name *

First Name Last Name

COVID-19 TESTING QUESTIONNAIRE *

	Yes	No
First COVID test?
Symptomatic as defined by CDC?
Employed in healthcare?
Hospitalized?
Pregnant?

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.
Patient/Guardian Signature *

Clear
Payment

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.
Should be Empty:

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

MEDICAL INSURANCE

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

Rapid COVID-19 Testing

Payment

Credit Card

Confirmation