SARS-CoV-2 ANTIGEN TEST QUESTIONNAIRE

How would you like to pay for your SARS-CoV-2 Antigen Test?*

I understand and agree that Pediatric People does NOT offer free testing through the CARES Act.

Insurance
Self Pay
Business Account

Do you have a business account that we should be bill for any amount your insurance doesn't pay?*

No
Yes

Business Account Number*

By using my employers business account as a full or partial payment method, I understand and agree that Pediatric People, PLLC will ONLY share my SARS-CoV-2 (COVID-19) Antigen Test Results with my employer. I understand and agree that I may may revoke this authorization by submitting a written revocation to Pediatric People’s Director of Administration. There is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient. Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation.

How would you like to send us photos of your DRIVERS LICENSE and/or INSURANCE CARD?*

If the patient does not have a drivers license, please upload the drivers license of a parent or legal guardian.

Upload Now
Send by Text (NOT recommended, may delay your appointment)

Please use your phone to take a photo of the following items and text them to 972-382-5796.

Drivers License
Front of Insurance Card
Back of Insurance Card

Please use your phone to take a photo of the following items and text them to 972-382-5796.

Drivers License

Please use your phone to take a photo of the following items and text them to 972-382-5796.

Drivers License

Upload a photo of the Patient or Legal Guardian's DRIVERS LICENSE*

If you are completing this form on behalf of your child, upload your identification. Drivers license or government ID, it must include your address.

Upload a photo of the FRONT of your INSURANCE CARD*

Upload a photo of the BACK of your INSURANCE CARD*

Are you the primary insured?*

Yes
No

Who is the primary individual on the insurance policy?*

Full Name	Date of Birth	Gender	Relationship to You

Payment Terms for Patients With Insurance*

You understand and agree that you will be required to keep a credit card on file for the SARS-CoV-2 Antigen Test. This card will be charged the amount you are responsible for automatically after your insurance settles the claim. The maximum amount you could be responsible for is $99.00 per test. No refunds.

Terms for Patients Paying with Credit Card*

You understand and agree that you will be required to keep a credit card on file for the SARS-CoV-2 Antigen Test. The self pay rate is $99 per test and will be charged to your credit card when you schedule your appointment. No refunds.

Notice of Privacy Practices*

I have reviewed and agree to Pediatric People PLLC's Notice of Privacy Practices dated October 1, 2013. I understand that I may receive a printed copy of this notice upon verbal or written request now or in the future. The notice may also be viewed on our website at PediatricPeople.com.

Consent for Medical Treatment*

There are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the doctor(s) and practice staff of Pediatric People PLLC to perform ALL necessary medical care. I understand that all medical treatments contain inherent risks.

Signature of Legal Guardian or Patient

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Reason	Year

Name of Medication	Reason