I hereby certify that the insurance information I am providing is active and accurate. I am giving consent for my COVID-19 testing to be submitted to my insurance. I am responsible for the partial/whole cost if my insurance only covers the partial cost of the test or in my insurance does not cover the cost of the test at all, or if the information I provided is inaccurate or invalid.
I verify that no other payer will reimburse for COVID-19 testing and that I currently do not have insurance.
By signing below, I verify that the above information is correct.