I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, private insurance and other health
plans, to this site. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as
valid as an original. I hereby authorize this site, to use, to disclose, and to release any of my personal and healthcare information to secure
payment. I authorize this site to release my medical information to any physicians and healthcare providers as well as adjusters, case
managers, vocational counselors, employers and pharmacists thought email or text even it not be secure. I further authorize any physicians
and healthcare providers to release my medical, laboratory, x-ray and diagnostic, pharmaceutical, and psychiatric records to this site. I
acknowledge that I have been informed of my rights under the Health Information Protection and Portability Act (HIPAA), I understand that I
may request copies of this information and rights any time. I hereby authorize this site, to use HIPAA-compliant telecommunication for
evaluating, testing and diagnosing my medical conditions.
I hereby authorize the specialist or personnel of this site/school to administer weekly testing for the aforementioned patient at the specialist's/personnel's discretion.
Nova Diagnostics Labs LLC will not bill insurance for patients taking free COVID-19 tests for the purposes of travel.
By signing this form and checking the box below, I understand that the free COVID-19 test I will be taking is not going to be used for the purposes of travelling.
NOTE: By signing below you agreed, understood, and abide by the disclaimer above.
NOTE: By not checking 'Expand to Generate Order' and clicking 'Submit' you will ONLY submit the patient information that will not be processed until it is approved by a Site Administrator.
NOTE: By checking 'Expand to Generate Order' and clicking 'Submit' you will submit both the patient information and the order information that will not be processed until it is approved by a Site Administrator.