HRSA Insurance

By filling out this information I am confirming that I am, in fact, uninsured at the time these services were rendered. As the patient I confirm I do not have coverage through an individual or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program. I also confirm that I am unable to afford this test at this current time. I understand the laboratory will apply through the HRSA for reimbursement for the COVID-19 test which my provider has determined is medically necessary.
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A SSN and state identification / driver's license is needed to verify patient eligibility. Please understand we cannot accept claims without this information. If you do not have a SSN or driver's license, please include your Passport ID number.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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