Covid-19 Testing

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Select Date

Select Time

Patient Information

First Name

Last Name

Middle Initial

Address

State

City

Postal Code

Date of Birth

Phone Number

Gender

Male	Female

- If you have insurance, please mark "for Insured". It may take up to 72 hours for results to come and most insurance will cover 100% cost you may have to pay $25 facility fee.
- If you are uninsured, please mark "for uninsured“. It may take up to 72 hours for results to come and lab will reach out to government for reimbursement.
- If you are traveling and need results withing 24 hours, please mark "Traveler", the cost for RT-PCR will be $130 (Cash only).

For insured (proof of insurance required)	For uninsured (government id & Social Security)
Traveler (Passport/Government ID required)

Please attach your insurance id(front) .jpg or .pdf should be more than 500KB or 300PI

Please attach your insurance id(Back) .jpg or .pdf should be more than 500KB or 300PI

Insurance Details

Insurance Company Name

Insurance Plan Name

Member/Subscriber ID

Group Number

Patient Relationship to insured Member/Subscriber

Self	Spouse
Child	Other

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Please attach your government issued id(front) .jpg or .pdf should be more than 500KB or 300PI

Please attach your government issued id(Back) .jpg or .pdf should be more than 500KB or 300PI

Patient Race(REQUIRED BY HHS AND CDC)

American Indian or Alaskan Native	Native Hawaiian or Other Pacific Islander(PI)	Asian(AS)
White	Black or African American(B)	Multiple/Other(O)

Patient Ethnicity

Hispanic/Latino(H)	Non Hispanic/Latino(N)
Asian(AS)

COVID-19 Clinical History(REQUIRED BY HHS and CDC)

First Test?	Yes	No	Unknown
Hospitalized For COVID-19?	Yes	No	Unknown
ICU For COVID-19?	Yes	No	Unknown
Resident in congregate care setting?	Yes	No	Unknown
Pregnant?	Yes	No	Unknown

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EIXSYS Healthcare System

Notice of Privacy Practices

This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment or healthcare operations and for the purposes permitted by law. Uses and Disclosures of Protected Health Information Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. We will also disclose your protected health to other physicians who may be treating you, or with other medical providers whom you have signed release of protected health information, or specific individuals you have identified in the “Exceptional Authorization” below

Exceptional Authorization

I authorize the release information including the diagnosis, records, examination rendered to me claims information. This information may be released to:

Spouse

Children

Other

* This release of information will remain in effect until terminated by me in writing

Other Permitted and Required Uses and Disclosures that may be made without your authorization or opportunity to agree or object:

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required by law:

We may use or disclose your protected health information to the extent that is required by law. The use or disclosure will be made in compliance with law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health:

We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, the disclosure may be made for the purpose of preventing or controlling disease, injury, or disability.

Communicable Diseases:

We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Abuse or Neglect:

We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Respond to organ and tissue donation requests:

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Health Research:

We can use or share your information for health research.

Respond to lawsuits and legal actions:

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Changes to the Terms of this Notice:

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Our Responsibilities:

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. HIPAA ACKNOWLEDGMENT OF RECEIPT I have been given the opportunity to read this Notice of Privacy Policy. I understand that Eixsys Healthcare System will only use and/or disclose PHI (Protected Health Information) for treatment, payment or healthcare operations.

Patient/Legal Guardian Signature

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After submitting your application, please check your email (Inbox/Span folder). Your email will contain a confirmation number and instructions. You must show your confirmation number and Government issued ID when you arrive for COVID-19 Testing.

BACK

Fever or chills	Cough
Shortness of breath or difficulty breathing	Fatigue
Muscle or body aches	Headache
New loss of taste or smell	Sore throat
Congestion or runny nose	Nausea or vomiting
Diarrhea	Others

Health care	Care for a person with a disability
Care for a person with a disability	Emergency services
Food services	Agricultural or food manufacturing
Public transportation	Correctional facility
Education	Others

COLOR OPTION

COVID-19 Testing

Testing will be conducting through PT-PCR Diagnostic Panel and specimen will be collected through Nasopharyngeal Swab.

1. Which of the following medical symptoms you have, please check all that apply.

2. Which one of the following categories are you employed in?