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    Appl Form OCL

    Uploaded by

    Nikki Gaskins Campbell
    This document provides information for COVID-19 testing through O'Hare Clinical Lab Services. It includes sections for reporter, patient, insurance, and clinical information as well as an attestation, disclaimer, and signature. The document requests basic identifying and insurance details, asks about underlying conditions, and has the patient attest that they do not have insurance if applying for reimbursement through HRSA. It disclaims the lab from liability and states results may be inaccurate or false. The patient agrees their information can be shared with arranging organizations and health authorities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Appl Form OCL

    Uploaded by

    Nikki Gaskins Campbell
    1K views2 pages
    This document provides information for COVID-19 testing through O'Hare Clinical Lab Services. It includes sections for reporter, patient, insurance, and clinical information as well as an attestation, disclaimer, and signature. The document requests basic identifying and insurance details, asks about underlying conditions, and has the patient attest that they do not have insurance if applying for reimbursement through HRSA. It disclaims the lab from liability and states results may be inaccurate or false. The patient agrees their information can be shared with arranging organizations and health authorities.

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    Appl Form OCL

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    © © All Rights Reserved

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    This document provides information for COVID-19 testing through O'Hare Clinical Lab Services. It includes sections for reporter, patient, insurance, and clinical information as well as an attestation, disclaimer, and signature. The document requests basic identifying and insurance details, asks about underlying conditions, and has the patient attest that they do not have insurance if applying for reimbursement through HRSA. It disclaims the lab from liability and states results may be inaccurate or false. The patient agrees their information can be shared with arranging organizations and health authorities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views2 pages

    Appl Form OCL

    Uploaded by

    Nikki Gaskins Campbell
    This document provides information for COVID-19 testing through O'Hare Clinical Lab Services. It includes sections for reporter, patient, insurance, and clinical information as well as an attestation, disclaimer, and signature. The document requests basic identifying and insurance details, asks about underlying conditions, and has the patient attest that they do not have insurance if applying for reimbursement through HRSA. It disclaims the lab from liability and states results may be inaccurate or false. The patient agrees their information can be shared with arranging organizations and health authorities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    COVID-19 TESTING

    1420 Renaissance Dr, Ste 206

    O’HARE
    Park Ridge Il 60068
    Phone: (800) 875-4307

    CLINICAL LAB SERVICES REQUEST FORM Fax: (847) 213-0501


    Email: [email protected]

    REPORTER INFORMATION
    DATE: ACCOUNT
    ORDERING PHYSICIAN: NPI: PHONE NO.

    PATIENT INFORMATION
    FIRSTNAME BIRTHDATE SEX

    / / Male
    Female

    LASTNAME: PHONE NO.

    STREET ADDRESS (Includeapartments/suite number)

    CITY STATE ZIP CODE

    INSURANCE INFORMATION
    MEDICARE # PRIVATE INSURANCE NAME

    POLICY ID GROUP ID
    NO INSURANCE
    INITIAL:

    CLINICAL INFORMATION
    Does the patient have underlying conditions? ADDITIONAL NOTE/S:

    None Immunocompromised Travel Date: / /


    Unknown Pregnant
    Diabetes Chronic Lung Disease
    Hypertension Chronic Liver Disease
    Cardiac Disease
    Others

    ATTESTATION
    If you like to receive your test results via email, please list your email address below.
    EMAIL:

    Reimbursement for COVID-19 testing is covered 100% by all insurance payers with no deductible, copays or coinsurance or any other out of
    pocket expense. Individuals will need to provide a copy of medical insurance card at the time of testing.
    Reimbursement for uninsured individuals COVID-19 testing are provided by Department of Health and Human Services’ Health Resources
    and Services Administration (HRSA). HRSA requires individuals to provide copy of state issued identification card and gned attestation that
    they do not have any medical insurance at the time of testing.

    I _______________________ attest that I do not have any medical insurance coverage at the time of this test.

    / /
    Signature or Parent/ Legal Guardian DATE
    (if Participant is under 18 years old, please have Parent or Legal Guardian Sign)
    DISCLAIMER

    In consideration for receiving the opportunity to participate in COVID-19 testing (hereinafter "Testing"), which is
    provided by O’HARE Clinical Lab Services, Inc. (the 'Company"), I hereby release, waive, discharge, covenant not to
    sue, and agree to hold harmless for any and all purposes Company and their healthcare staff, members, shareholders,
    officers, servants, agents, volunteers, or employees (herein referred to as “indemnitees”) from any and all liabilities,
    claims, demands, injuries (including death), or damages, including court costs and attorney's fees and expenses, that
    may be sustained by me while participating in Testing, while traveling to and from the Testing, or while on the
    premises owned or leased by Indemnitees.

    I am fully aware that the Testing provided by Company may involve COVID-19 tests that have not gone through a
    full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending
    such processing and that the results could produce false positives or false negatives, or be administered in a way
    that otherwise produces inaccurate results. I am also fully aware that the Company is not providing medical care
    or giving a medical diagnosis with Testing and that I should consult my doctor or go to an emergency room if I have
    a serious symptom and/or to obtain medical advice from my own doctor as to the results of the Testing.

    I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete
    the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the
    organization which has arranged for the testing, and (2) local and state public health authorities (which may result
    in further direct communication from those entities to me for further follow-up and contact tracing). Protected
    health information will not be reused or disclosed by Company to any person or entity other than above, except as
    required by law.

    By signing below, I am agreeing to voluntarily testing. In signing this agreement, I acknowledge and represent
    that I have read it. understand it, and sign it voluntarily.

    / /
    Signature or Parent/ Legal Guardian DATE
    (if Participant is under 18 years old, please have Parent or Legal Guardian Sign)

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