Please enable JavaScript in your browser to complete this form.
COVID-19 Lab Test Order
Thank you for taking the time to register for your rapid COVID-19. This helps ensure the safety of our staff and other patients by minimizing contact.
STEPS TO GET TESTED:
1) Complete this form. 2) If you have not booked your appointment, go to
https://statresearch.com/covid-19-testing/
and choose the location to get tested. Complete the booking and make payment for the test. 3) Arrive for your test on-time.
Please enable JavaScript in your browser to complete this form.
Patient Is ..
17 years or younger
18 years or older
Legal Guardian Completing This Form
*
First
Middle
Last
Patient Name
*
First
Middle
Last
Patient Date of Birth
*
Patient Sex
Female
Male
Undisclosed/Other
Patient Home Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Company Name (If Paid for under a corporate testing program)
This only applies if your company has a service agreement with STAT Research and will be paying for your test directly. You agree that a copy of your test results can be sent to your employer.
Cell Phone
*
Email
*
Agreement
18-Years Old
*
I certify that I am 18 years old or older.
Legal Guardian
*
I certify that I am the legal guardian of the patient to be tested, or otherwise authorized by the patient's legal guardian to have this test preformed.
Insurance Billing
*
I understand that, because a physician has not ordered this test, my health insurance (including Medicare and Medicaid) will not pay for this test. I will not ask my health insurer, Medicare, Medicaid, or any other state or federal health care program to pay for this test. Payment is due at the time of service.
Insurance Reimbursement
*
I understand that STAT Research will not submit this test for reimbursement or payment to my health insurer, Medicare, Medicaid, or any other state or federal health program, or a third-party payer.
Self-Ordered Test
*
I understand that STAT Research does not replace the advice or care of my physician by offering this test. It is intended for educational purposes. A STAT Research lab test result is not a medical diagnosis, a treatment, or a form of medical advice. I am solely responsible for promptly talking with my physician about my lab test results. I understand that only my health care provider can interpret the test results.
Hold Harmless
*
I release and hold harmless STAT Research for failing to report the test results to my physician and/or seeking medical advice based on the test results.
FDA Authorization
*
I understand that this test has not been FDA cleared or approved. This test has been authorized by FDA under an Emergency Use Authorization (EUA) for use by laboratories certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, in a patient care settings operating under a CLIA Certificate of Waiver.
False-Negative and False-Positive Results
*
I understand and agree that negative results should be treated as presumptive and tested with an alternative FDA authorized assay, if necessary, for clinical management, including infection control. False-negatives or false-positive results are possible. This happens for various reasons, including but not limited to the levels of the virus present in the specimen, equipment malfunction, amplification inhibitors are present in the sample, improper collection, transportation or handling, and/or other reasons. Knowing this, I agree to release and hold harmless STAT Research for any false-negative or false-positive results.
Rapid Test
*
The rapid COVID-19 assay provided by STAT Research is not a Polymerase chain reaction (PCR), and the results of this test may not be sufficient for travel purposes or return to work. You understand and accept that STAT Research does not offer a refund for the test, and is not responsible for tests performed which are not accepted for the purposes intended.
Test Specificity
*
I understand this test cannot rule out diseases caused by other bacterial or viral pathogens.
Reporting Requirements
*
I understand that STAT Research is obligated to report positive SARS-CoV2 to the County health department, including your personal health information (PHI) listed on this form.
Notification of Results
*
STAT Research will provide a lab report to you within the timeframe listed for the particular test. A text message notification will be sent to your phone when the test results are completed. You may download them online using our secure portal, or by going to lab.statresearch.com.
Authorization
*
I accept and agree to the terms of the test as described in this agreement. I understand that payment for test is required prior to being tested.
Captcha
*
=
Submit
