COVID testing INSURANCE

· There is potential for 2 swabs to be collected during your visit. The first is for the rapid test and the second is for the PCR test. If you are requesting only a PCR for travel/by choice we will NOT run the rapid unless requested.
· The nose swab test goes to the front of the nose (NOT a deep swab).
· Little Village Pediatrics charges the following:

1) $75 for the rapid COVID antigen test with the COVID PCR back up

2) $50 for rapid COVID antigen only

3) $50 for COVID PCR only testing

· Please complete this form to set up time for testing. Dr. Davidson will call or email you to set up testing time once form received.

*IF YOU DO NOT HAVE INSURANCE YOU WILL LIKELY RECEIVE A BILL FROM LABCORP FOR $100-125. THE GOVERNMENT IS NO LONGER PAYING FOR COVID PCR TESTS FOR UNINSURED PATIENTS. THE EMERGENCY FUNDS FOR THIS STOPPED ON 3/22/2022.

*IF YOU HAVE INSURANCE PLEASE COMPLETE ALL INFORMATION BELOW. IF YOU RECEIVE A BILL FROM LABCORP AFTER THE TEST IS COMPLETE YOU SHOULD CALL THEM DIRECTLY TO ENSURE THEY HAVE ALL OF YOUR PROPER INSURANCE INFORMATION ON FILE. I DO NOT RECOMMEND PAYING BILL UNTIL SPEAKING WITH THEM FIRST. I DO NOT KNOW IF YOUR INSURANCE WILL PAY FOR YOUR COVID PCR TEST OR NOT, THIS IS SOMETHING YOU CAN ASK YOUR INSURANCE COMPANY ABOUT DIRECTLY.

Patient Name*

First NameLast Name

Date of Birth*

Date

Sex (male or female)?*

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please e-mail results to:*

example@example.com

Phone Number*

Please enter a valid phone number.

Date*

Date

Parent / Guardian to Contact with Results*

First NameLast Name

Parent/Guardian Phone Number*

Please enter a valid phone number.

Reason for Test:*

Date Symptoms started (if having symptoms)

Rapid Covid Antigen Test with PCR back up ($75)Rapid Covid Antigen Test only ($50)COVID PCR Sent Out Test only ($50)

Do you want testing in your car or inside office?

Acknowledgements:
1) I understand that the PCR test will only be sent if the rapid test is negative, unless I am specifically requesting PCR test or rapid test only.
2) I understand that I must pay prior to being tested. I understand Little Village Pediatrics has no control over insurance reimbursement.
3) I understand that Dr. Davidson is not my physician. All questions regarding symptoms and results must be directed toward my own primary care physician.

4) I understand that Little Village Pediatrics as required by law must report certain diseases to local and state agencies.

Insurance Carrier (only if you have insurance)

Name of Policy Holder

Member Numer/ID

Group Number

City/State to mail claims (look on back of card, if unknown leave blank)

Date/Time Request - Dr. Davidson will contact you to set up via email/call.

Signature*

Name*

First NameLast Name

Rapid Antigen/Send out PCR COVID TESTING