Requisition Form
Testing Center
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Montessori Stepping Stones
Daystar Academy
Chicago Police District
Walled Lake Consolidated School District
CDL1000 Lyons
CDL1000 Chicago
American Montessori Academy South Loop
Amata
If Chicago PD, what district?
Pick your test
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COVID-19 PCR Test
COVID-19 Rapid Antigen Test
Name of Parent / Guardian (if completing for minor)
Patient Information:
Patient Name
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Race and Ethnicity
*
Unknown
Asian
African American
Caucasian
African Indian
Native Hawaiian
Multi-Racial
Alaskan Native
Other
Contact Information:
Phone Number
*
Please enter a valid phone number.
Email address for RESULTS
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information:
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Insured (if so please fill out insurance information below)
Uninsured (if so please fill out payment method below)
Please upload photos of the front and back of your insurance card AND fill out the following 4 questions.
Upload/Take a Photo
Drag and drop files here
Choose a file
Please provide clear images of the front and back of your insurance card.
Cancel
of
Insurance Carrier
Group #
Member ID / Policy #
Policy Holder / Subscriber
Relation to Policy Holder
*
Self
Spouse
Dependant
N/A
Photo Identification (If patient is a minor, please upload parent/guardian ID)
*
Upload/Take a Photo
Drag and drop files here
Choose a file
Please provide a photo of your state issued driver's license, state ID, passport or any photo identification.
Cancel
of
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COVID RT-PCR Test Kit
$
110.00
COVID Rapid Antigen
$
50.00
Credit Card
Consent:
I certify that I have voluntarily provided a fresh specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. I hereby authorize AirBioLab or it's billing entity to bill any and all insurance/health coverage on my behalf for laboratory services rendered by a performing CLIA laboratory. I irrevocably assign to and direct that payment to be made to ABL. I also authorize ABL to release any information required for billing and reimbursement. I further authorize a performing CLIA laboratory to release the results of this testing to the treating authorized health care provider or facility. I acknowledged that ABL may be out of network facility provider with my insurance provider. I am also aware that in some circumstances my insurance provider may send payment directly to me. I agree to endorse the insurance check and forward it to ABL within 15 days of receipt as payment towards the lab services provided by a performing CLIA laboratory. I acknowledge that I am responsible for any amounts not covered by my insurer including any deductibles and copayments or co insurance. I understand that a performing CLIA laboratory may use my specimen for research and development so long as the information has been identified pursuant to the law.
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I acknowledge that documentation to support medical necessity for all tests ordered is recorded in the patients chart. If not signed, authorized health care provider affirms that test orders are placed in a patient file with provider signature and will be available upon request. The office of the Inspector General requires documentation in patient medical chart including data service, tests ordered and documentation to support medical necessity.
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I understand that I am not entering into a doctor-patient relationship with AirBioLab, (ORDERING ENTITY), or (ORDERING MEDICAL PROVIDER), and that any questions or required follow up shall be my responsibility to arrange with my own physician.
*
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