Alternative Payment Method

This company does not accept all insurance payers. You may choose to file you claim by submitting a copy of this receipt to your insurance carrier. This company accepts no responsibility on how your insurance will respond to your claim or whether the service is a covered benefit.

I (we) hereby authorize this company to initiate a change to my (our) credit card to pay for the services rendered. I(we) acknowledge that the origination of such transactions to my (our) account must comply with the provisions of US law.

I , request and permit these provider to analyze the sample indicated on the test requisition form in My sample, My child's sample. No testing apart from that which is selected will be performed. Additional testing requires my additional, express consent.

By signing below, I attest to the following:

1. I have been informed of the likelihood of confirming a diagnosis and test result.
2. I have been informed that the test kit is authorized by FDA under EUA
3. I have read and understand the information provided on this form and have had an opportunity to have any questions answered by my healthcare provider.
4. HIPAA - I acknowledge that I have received a copy of this providers Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.
5. Assignment of Benefits - I request that payment of authorized benefits and/or authorized Medicare benefits be made on my behalf to Company Name for any services or items furnished to me by this company. I assign and transfer to this company all rights to receive insurance benefits otherwise payable to me for products or services provided by this company. I understand that I am financially responsible to this company or any charges not covered by health care benefits. I am responsible for the entire bill or balance of the bills as determined this company or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services provided to me. I understand that this company has the right to pick up the equipment if the insurance will not pay the full purchase price and other financial arrangements cannot be made to pay the balance of my account. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act, or under a policy of insurance is correct. It is my responsibility to notify this company of any changes in my health care coverage. This company does not accept all insurance payers. You may choose to file your claim by submitting a copy of this receipt to your insurance carrier. This company accepts no responsibility on how your insurance will respond to your claim or whether the service is a covered benefit.
6. Release of Information - I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determined these benefits or the benefits payabale for related services. I further authorize this company and/or any other holder of my medical information to release and/or receive such information to enable them to review, audit, bill and/or provide equipment, products and services. I also give my consent for third party (such as accreditation) to review of all my information. I permit a copy of this authorization to be used in place of the original. Responsibility for overpayment on assigned claims accepted