COVID-19 CONSENT FORM

PATIENT INFORMATION
Please have the following ready:

Driver's license Insurance card

COVID-19 Testing Consent Form
Name

First NameLast Name
MI
Date of Birth MM/DD/YEAR
Gender

FemaleMale
Other

SingleMarriedOther
Social Security Number
Phone number
Email
example@example.com
Home Address
Apartment #
City
State
Zip Code
County
Medicare Plan Number
Medicaid Plan Number
Private Insurance Company Name
Member ID#
Group #
Insured Name/DOB
Relationship to insured
Upload Drivers License

Cancelof
INFORMED CONSENT FOR COVID-19 TESTING FOR THE INSURED AND UNINSURED
Please read the informed consent carefully.

I, authorize FOREVER YOUNG DIAGNOSTICS to conduct collection for free or Rapid COVID-19 testing througha nasopharyngeal swab. 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 per the current CDC guidelines 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 FOREVER YOUNG DIAGNOSTICS 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 FOREVER YOUNG DIAGNOSTICS is not acting as my Primary Care Provider. 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 understand that, as with any medical test, there is the potential for false positive or false negative test results.

I understand that Rapid COVID-19 testing is available for cash, debit/credit 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
Date

MonthDayYear
Date
Relationship to Patient
OFFICE USE ONLY (DO NOT WRITE BELOW)

Free COVIDInsurance COVIDRapid Antigen TestRapid Antibody Test
Should be Empty:

PATIENT INFORMATION

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