Assignment of Benefits For Patients Receiving the PCR Molecular NAAT COVID-19 Test

I confirm that I am the patient or have the right to provide consent on behalf of the patient and acknowledge that the information I have provided is true. I hereby authorize the insurance benefits to be paid directly to a third-party laboratory and authorize the third-party laboratory to release medical information concerning the test to the insurer. If applicable, I authorize the third-party laboratory to be the Designated Representative for purposes of appealing the denial of benefits. I acknowledge and agree that the third-party laboratory has the right to request medical records, pedigrees and clinical/family history notes directly from my provider(s) for the purposes of insurance verification and proper billing. I also understand that if the insurance company sends payment to the patient or I, I or the patient will be responsible for forwarding the payment to the third-party laboratory for performing the COVID-19 PCR Test.

I understand that as a courtesy, Covid Clinic and/or a third-party lab will make every reasonable effort to obtain insurance reimbursement for ordered tests. I understand that I am making an assignment of my insurance plan benefits to Covid Clinc and/or a third-party lab. I also authorize the release of any information contained in my records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with the same. I understand that if my insurance company pays me directly for services rendered by Laboratory, I am responsible for forwarding such payment to Laboratory.

I acknowledge that the information provided by me is true to the best of my knowledge. For direct insurance/3rd party billing: I hereby authorize my insurance benefits to be paid directly to MedLab2020 and authorize them to release medical information concerning my test to my insurer. If applicable, I authorize MedLab2020 to be my Designated Representative for purposes of appealing and denial benefits. I acknowledge and agree that MedLab2020 has the right to request medical records, such as consult notes, pedigrees and clinical/family history notes directly from my provider(s) for the purpose of insurance verification and proper billing. I also understand that I am legally responsible for sending the Billing Laboratory any more received from my health insurance company for performance of this generic test.

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