Nova System

Covid Relief Centers

Sat, 03 Jun 2023

Create Your Patient Profile

Patient Information

Patient's First Name *

Patient's Last Name *

MRN (ex. Passport Number)

Client Record Number

Scan Bar Code

Street Address *

Press the search icon to lookup and autocomplete your address!

City *

State *

Zip Code *

Cellular Phone Number *

Patient's Date of Birth *

Email *

Gender *

Ethnicity *

Race *

Goverment Issued ID # *

Upload Image of License or ID *

Upload

PLEASE CHECK IF APPLICABLE

The patient is a Minor

The patient is over 18

PLEASE CHECK IF APPLICABLE

Insurance

Cash

I accept and understand by signing this health care waiver I agree to accept the COVID-19 test based on my medical insurance coverage.

I am not enrolled or covered by any insurance coverage

I am enrolled or covered by any insurance coverage

Primary Insurance Company Name *

Primary Insurance Member ID/Account Number *

SSN *

Upload an image (or, if on mobile, take a picture) of the front of your insurance card *

Upload

Take a picture of the back of your insurance card

Upload

Patient or Parent/Guardian

First Name *

Last Name *

Disclaimer

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.

I understand * This field is required.

NOTE: By signing below you agreed, understood, and abide by the disclaimer above.

Signature

Collection Specialist *

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.

Expand to Generate Order

Order Information
This Section To Be Completed By Collection Specialist

COVID-19 Test Type(s) *

Covid-19 by RT-PCR-24

COVID-19 Antigen Test

COVID-19 Antibody Rapid

Covid-19 by RT-PCR (A+B)

This field is required.

Collection Method *

Dx Code(s) (or ICD Code(s)):

Rapid Result Status *

Rapid Test Result *

Image of Rapid Test Kit *

Upload

Patient's Temp

Image of Tube

Upload

Proof of Test

Upload

Collection Date *

Client *

Site *

Location

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.

Note

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Covid Relief Centers

Patient Information

Patient or Parent/Guardian

Disclaimer

Order Information This Section To Be Completed By Collection Specialist

Order Information
This Section To Be Completed By Collection Specialist