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Covid-19 Testing - Information Form
In-Home, Office & Hotel COVID-19 Tests. If you need help, please call 305-306-1920 . We come to you within the hour and administer a COVID-19 test. Depending on which test you choose, you’ll receive your results within 15 minutes to 36 hours.
Patient Name:
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First Name
Middle Name
Last Name
Sex:
*
Male
Female
Date of Birth (MM/DD/YYYY):
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Month
-
Day
Year
Date
Passport Number
Please Enter Your Passport Number
Social Security #:
Please Enter Your Social Security Number
Address: (Testing site address if different than home address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Email:
*
example@example.com
Preferred Appointment Time (We will confirm appointment) 24 Hours Service
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I understand that this charge is non-refundable within 24 hours of the appointment and by clicking "submit" my credit card will be charged for the appointment.
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I Agree
Signature
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Release and Consent - I authorize and release of my medical information including test results for submission of personalized reports to the appropriate Federal, State and Local health agencies in the event of a positive result for COVID-19. I also authorize the release of results and information to my healthcare providers and insurance carriers(s) if requested with regards to a positive result. I understand that, it is possible to receive negative result for COVID-19 in the event my exposure to the virus is recent or if a specimen received has a quantity not sufficient of DNA to appropriate result for a positive or negative to COVID-19. I do hereby indemnify and hold harmless ConciMed LLC, its officers, agents, representatives and assigns for any result, whether positive or negative, from any liability as result of this test and /or its results. I understand that ConciMed is NOT a specimen banking facility and my sample will NOT be available after 60 days for future clinical studies. De-Identify samples may be stored in a repository and used internally for validation, educational, and/or research purpose OR presented in scientific presentations or papers. In addition, de-identified information may be submitted in a HIPAA-compliant manner to research databases. CLIA ID #10D2212516 National Provider ID: 1467042978
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EXPEDITED RT-PCR
$
395
EXPEDITED RT-PCR • Detects SARS-CoV-2 presence • Nasal swab • In-home services • FDA Approved • CLIA-Certified laboratory • Approved for international travel • *PCR Test Performed by 11 AM - Results same day
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NASAL SWAP RT-PCR -RESULTS 10-36 HOURS
$
295
NASAL SWAP RT-PCR • Detects SARS-CoV-2 presence • Nasal swab • In-home services • FDA Approved • CLIA-Certified laboratory (Required for International Travel) • Results in 10-36 Hours
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RAPID ANTIGEN TEST - 15 MINUTE RESULTS - (SARS-CoV-2)
$
150
RAPID ANTIGEN TEST • VERBAL & EMAILED RESULTS IN 15 MINS • Detects SARS-CoV-2 presence • Nasal swab • In-home or on-site • FDA Approved • Not suitable for international travelers (RT PCR REQUIRED)
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RAPID ANTIBODY TEST (IGM, IGG) - 15 Minute Results
$
150
Rapid Antibody Test (IGM, IGG Serology) • RESULT IN 15 MINS • Detects past infections • Blood sample needed • In-home or office services • FDA Approved • CLIA-Certified laboratory • Get results in 15 minutes via email
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Nasal Swab RT-PCR - Insurance or Signed Affidavit
$
125
Results In 24-48 Hours Via Email Detects SARS-Cov-2 Presence Nasal Swab In Your Home, Office, Or Hotel FDA Approved CLIA-Certified Laboratory Covered by Insurance* *or signed affidavit of non-insured)
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Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Enter Full Name and Date of Birth of All Individuals Being Tested.
Do you have insurance?
Yes
No
FOR UNINSURED PATIENTS*By checking a box below or by signing the form, you acknowledge that you are not currently enrolled in any private, individual (non-group or COBRA) or group (employer or other organization-sponsored) health insurance plan, any federal health care program(including but not limited to Medicare, Medicaid or TRICARE), nor am I covered under the health insurance of a spouse or parent.
I confirm that I am not currently enrolled in private, individual, group, or federalhealth plans.
CONSENT TO TEST AND BILL INSURANCE FOR THIS AND FUTURE COVID TESTS IN ADDITION YOU CONSENT TO SHARE YOUR INFO WITH THOSE INVOLVED WITH THE COLLECTION AND PROCESSING OF YOUR LAB TESTS
*
Patient Acknowledgment: I am covered by insurance an authorize Gene By Gene, LLC to give my designated insurance carrier(s) plan on this form and other information provided by my health care provider necessary for reimbursement. I authorize Gene By Gene, LLC to inform my Plan of my test results only if test results are required for preauthorization of or payment for reflex/additional testing. I authorize Plan benefits to be payable to Gene By Gene, LLC. I further authorize payment of benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I understand any payment I receive for services rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory.Patient Consent: My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing have been explained to my satisfaction by a qualified healthprofessional.
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