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CARES Act Acknowledgement

Acknowledge
I am requesting Flo-MediLab to submit for reimbursement from HRSA under the CARES Act and I attest to the following:
1. I am uninsured. I do not have coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered.
2. No other payer will reimburse me for COVID-19 testing and/or care.
3. I understand that claim submission from HRSA under the CARES Act is not a guarantee of payment and if the CARES Act fund does not cover the claim, I will be responsible for the full balance.
4. I agree to program terms and conditions and may be subject to post-reimbursement audit review.

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PHYSICIAN SIGNATURE:

The ordering authorized Health Care Provider understands and hereby acknowledges that (a) the tests ordered are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s clinical file and the Health Care Provider is responsible for assigning and providing specific ICD-10 code(s) to support the medical necessity of any and all laboratory tests; and (b) the Health Care Provider must make a determination that medical necessity exists each time a specimen is submitted. Read more

PATIENT

PROVIDER

First Name:

First Name

Last Name:

Last Name

DOB:

DOB

Gender:

Gender

Country:

Country

Address:

Address

Address 2:

Address2

City:

City

State:

State

Zip Code:

Zip Code

Email:

Email

Phone No:

Phone No

Patient Ethnicity:

Patient Ethnicity

Weight (lbs.):

Weight (lbs.)

Height :

Height

Social Security Number:

Social Security Number

Barcode:

Barcode

Insurance Type :

Insurance Type

Bill to:

Bill to

Illness/Accident Date

Illness/Accident Date:

Accident Type :

Accident Type

Accident State:

Physician Name:

Physician Name

NPI:

NPI

Insurance Detail

COLLECTION DETAILS

DIAGNOSTIC CODES

Collected Date:

Date of Collection

Time Of Collection:

Time Of Collection

Collector Name:

Collector Name

Specimen Type:

Infectious Disease Test Order

Physician Signature / Date

Patient Signature / Date

Back Submit

Self	Spouse
Dependent	Other

Session Expiration

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notifications

PHYSICIAN SIGNATURE:

PATIENT SIGNATURE: