Covid-19 PCR Test

Please correct the errors described below.

17020 Beaver Springs Dr. Suite 8
Houston, TX, 77090
Tel. (832) 940-9996



Clia ID Number: 45D2185208

1. Patient Information

2. Specimen Information

AM / PM

3. Test Order

4. Patient Acknowledgment

I certify that I have voluntarily provided a fresh and unadulterated specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. I hereby authorize Genview Diagnosis or its assignee to bill any and all insurance/health coverage on my behalf for laboratory services rendered by Genview Diagnosis. I irrevocably assign to and direct that payment be made to Genview Diagnosis. I also authorize Genview Diagnosis to release any information required for billing and reimbursement. I further authorize Genview Diagnosis to release the results of this testing to the treating authorized healthcare provider or facility. I acknowledge that Genview Diagnosis 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 Genview Diagnosis within 15 days of receipt as payment towards the lab services provided by Genview Diagnosis. I acknowledge that I am responsible for any amounts not covered by my insurer including any deductibles and co-payments co-insurance. I understand that Genview Diagnosis may use my specimen and any testing performed on that specimen for research and development so long as the information has been de identified pursuant to law.

This specimen was provided voluntarily for analysis and I authorize Genview Diagnosis to process. Payments are non-refundable.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

5. Authorized Healthcare Provider Acknowledgement

I acknowledge that documentation to support medical necessity for all tests ordered is recorded in the patient's chart. If not signed, Authorized Healthcare Provider affirms that test orders are placed in patient file with provider signature and will be available upon request. The Office of the Inspector General requires documentation in patient medical chart including date of service, tests ordered.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

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