Application for Coverage of Respiratory Panel Testing

Complete this application to get help paying for certain Respiratory Panel Testing, testing-related, and treatment costs.

The health coverage you will get if you are found eligible using this application will only pay for medical tests for coronavirus.

To see if you are eligible for other health care benefits and services through Medi-Cal or Covered California, you should complete a full application at www.coveredca.com.

First Name *

Last Name *

Gender *

male
female

Date Of Birth *//

Email *

Phone *

Race *

Are you using the report for traveling? *

YES
NO

Choose *

If you choose no insurance, you will be charged 150 dollar on site

Insurance Name: *

Member ID *

Address: *

Address Line 1

City

State

Zip Code

Have you experienced any of these symptoms? *

You will be tested the following specific virus / bacteria

Disclaimer

Consent for medical care, specifically Respiratory Panel Testing, herby voluntarily consent to the rendering of such care including all services required to perform a Respiratory Panel test (PCR) by authorized members of PACGENOMICS as may in their professional judgement be necessary. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or testing. I have read this form and certify that I understand its contents. I hereby give my consent to PACGENOMICS who will be performing Covid-19 testing and Respiratory Panel Testing. I acknowledge that PACGENOMICS will bill my insurance for all testing and that I will not be responsible for any payments to PACGENOMICS. Consent to Email and/or Text Message for Appointment Reminders and Other Healthcare Communications: Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, and to provide general health reminders/information. I consent to receiving appointment reminders and other healthcare communications/information atthat email and/or text. I, myself or Guardian of First Name Last Name, do hereby consent and acknowledge my agreement to the terms set forth in the above CONSENT FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. I HEREBY AUTHORIZE THE ABOVE ORDERED TESTING AND I ALLOW THE RELEASE OF ANY MEDICAL INFORMATION TO AUTHORIZED MEMBERS OF PACGENOMICS LAB By signing below I agree to receive email messages with my results. I agree to testing consent.

Signature *

Note: Authorized Name and Signature is required if patient is under the age of 18.

Driver’s license/Passport:

Upload your Photo ID and Insurance Card *

Click or drag files to this area to upload. You can upload up to 2 files.

Date / Time

Date

Time