Covid-19 Rapid Antigen Test: Insured


If any information is false, you will be billed for the out-of-pocket cost.
Medicare/Medicaid Accepted

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Insurance Information: Bring Insurance Card During Visit

 

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PATIENT CONSENT: My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing have been explained to my satisfaction by a qualified health care professional. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any other time. I voluntarily agree to the test. If signature is other than the patient’s signature, print name. I hereby expressly waive and release any and all claims, now known or hereafter known, against Texas Star Med Clinic LLC, Covid Testing Solutions LLC and its officers, directors, employees, agents, affiliates, members, successors, and assigns, on account of injury, death, or property damage arising out of or attributable to my participation in the testing, whether arising out of the negligence of Texas Star Med Clinic LLC, Covid Testing Solutions LLC or any other releasee, and forever release and discharge the company and all other releasees from liability under such claims. I intend my signature to be the required evidence of my assent to completely and unconditionally release all liability for the greatest extent allowed by law. By signing below, I acknowledge that I have read and fully understood all of the terms of this agreement.

 

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize payment to TEXAS STAR MED CLINIC LLC. I represent that I have insurance coverage and do hereby authorize TEXAS STAR MED CLINIC LLC to release and obtain all information necessary to secure payment of said benefits. If my insurance fails to pay TEXAS STAR MED CLINIC LLC for any reason, I agree to pay all unpaid balances.

I HAVE READ AND UNDERSTAND MEDICAL PRODUCT DISCLOSURE, MEDICARE ASSIGNMENT, AND ASSIGNMENT OF INSURANCE BENEFITS AND AGREE TO ALL TERMS STATED.

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Signature Certificate
Document name: Covid-19 Rapid Antigen Test: Insured
lock iconUnique Document ID: 5a6f399f86ec813b9c3271dda2c155272ecbb887
Timestamp Audit
March 22, 2021 7:39 PM EDTCovid-19 Rapid Antigen Test: Insured Uploaded by Joseph Berro - contact1@yesnocovid.com IP 76.235.210.79
April 23, 2021 11:32 AM EDT Document owner contact1@yesnocovid.com has handed over this document to contact@yesnocovid.com 2021-04-23 11:32:37 - 76.235.210.79