Assignment Of Benefits For Patients Receiving The $0 Diagnostic Antigen Test

I am voluntarily submitting this specimen for analysis by Covid Clinic and/or a third-party lab. I authorize Covid Clinic to process or send my specimen and my medical and payor information to a third-party lab for processing and for the third party lab to release the test results to Covid Clinic. I understand that Covid Clinic and/or the lab(s) to which Covid Clinic sends my specimens may use my specimen and any testing performed on that specimen for research, development, or commercial purposes so long as the information has been de-identified pursuant to law.

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.

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