Self Ordered Test - STAT Research

Patient Is ..

17 years or younger
18 years or older

Legal Guardian Completing This Form *

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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

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.

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