Covid-19 Rapid Antigen Test: Uninsured


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

Signs & Symptoms:

Location of Test: • Date of Testing:

 

 

Name:  

 

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Identification:  

 

 

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.

 

PATIENT FINANCIAL RESPONSIBILITY: I understand that I am agreeing to have Texas Star Med Clinic LLC, Covid Testing Solutions LLC provide this test at no charge if I can provide evidence to support that I carry no medical coverage at the time of testing. I understand that in order to receive this service for free that my information will be ran through a system that identifies medical coverage’s and if it is determined that I had medical coverage after I have already been tested than the financial responsibility falls back on me and I will be billed for services at that time. If you are not covered by insurance at the time of your appointment, we will bill HRSA government program through the CARES ACT.

 

CONSENT FOR MINORS


I am the parent or legal guardian of the minor named above. I have the legal right to consent to and, by signing below; I hereby do consent to the terms and conditions of this Document.

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Signature Certificate
Document name: Covid-19 Rapid Antigen Test: Uninsured
lock iconUnique Document ID: ee4aed5ebbb0c441c23121b23a3313d8a528dfaf
Timestamp Audit
March 31, 2021 4:30 AM EDTCovid-19 Rapid Antigen Test: Uninsured Uploaded by Joseph Berro - contact1@yesnocovid.com IP 76.235.210.79
April 23, 2021 11:31 AM EDT Document owner contact1@yesnocovid.com has handed over this document to contact@yesnocovid.com 2021-04-23 11:31:51 - 76.235.210.79