Baltimore City Free PCR Covid-19 Registration Form

Dr ID
INSURANCE INFORMATION

If you do not have insurance, write 1353 COVID FUND
Primary Insurance Name*
If you do not have insurance enter the following in each field "1353 COVID FUND" and the government will pay for your PCR lab test.
Primary Insurance Address

Street Address

Street Address Line 2

CityState

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Primary Insurance Patient ID*
If you do not have insurance, write 1353 COVID FUND
Primary Group Number*
If you do not have insurance, write 1353
Patient Relation to Insured
Do you want to add secondary insurance?

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Secondary Insurance Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Secondary Group Number
If you do not have insurance, write 1353
Secondary Insurance Name
Secondary Insurance Patient ID
HIPAA Authorization and Waiver of Liability

The undersigned has requested a COVID-19 and/or other respiratory pathogen diagnostic test for the undersigned and/or the minor child of the undersigned at the drive-through ACCU Testing location located at The Baltimore City Location at 3500 W Northern Parkway Baltimore, MD 21215.

The undersigned hereby releases from any liability ACCU Testing, all of the staff and individuals performing the testing swabs, Baltimore City employees, and any other entity involved in hosting the ACCU Testing COVID-19 Testing, and all of their respective officers, directors, employees and agents.

The undersigned authorizes ACCU REFERENCE MEDICAL LABS and ACCU Testing, Dr. Yosef Levenbrown, Dr. Julian Jakobovits and any other healthcare provider I designate in writing as a recipient of the protected health information referenced herein.

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*

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If on behalf of minor child, name of child
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Baltimore City Free* PCR Testing Registration

THURSDAY FEBRUARY 24TH WILL BE THE LAST DAY THIS SITE WILL BE OPEN. AFTER THAT, PLEASE VISIT OUR BALTIMORE COUNTY TESTING CENTER LOCATED AT 122 SLADE AVE SUITE 101 PIKESVILLE, MD 21208. REGISTER AT WWW.ACCUTESTINGCENTER.COM

Results will be available in approximately 72 hours. You will recieve an email when your results are ready. If you have not recieved your results after 72 hours, you can contact baltimore@accureference.com for assistance.

INSURANCE INFORMATION