Patient COVID-19 Requisition Form

Test and Report Method
Test Menu*

RT-PCR of saliva specimen (Standard Turnaround ONLY)RT-PCR of swab specimenRapid antigen test (+$30, payment next page, ONLY available at our Wood Dale Lab)
If your specimen tests positive for COVID-19, Neelyx will attempt to identify the variant of COVID-19 and will report this information to you. This report may help you and your doctor determine the appropriate therapeutic next steps.
Results Report Method*

Email (consent required)Postal Mail
RT-PCR Test Turnaround*

Standard (24-48 hours)Expedited results +$150 (same day by midnight - 1am, payment next page, ONLY available at our Wood Dale Lab)
Antigen Specimen Identifier (Label on test)
Can't scan QR code? Enter the label here:

Form of Identification

Please provide a form of identification (e.g. drivers' license)
Identification upload method

Take photoUpload file
Front*
Back*
Identification card upload*

Cancelof

Test payment

Enter the antigen test barcode here:*
6 letter code

Healthcare Provider and Insurance
Physician's (PCP) Name
PCP Email Address
PCP Phone Number
INSURANCE INFORMATION
Payment options*

InsuranceUninsured
Social Security Number (SSN)*
No Social Security Number? Check below.

By checking this box, I attest that I do not have a Social Security Number (SSN).
Insurance Card

Please provide a copy of your insurance card.
Insurance card upload method

Take photoUpload file
Front*
Back*
Insurance card upload*

Cancelof
Insured Name*
Insured Relation*
Insured Social Security Number (SSN)*
If the insured person does not have a Social Security Number (SSN), check below.

By checking this box, I attest that the insured person does not have a Social Security Number (SSN).
Insured Member ID*
Insured Group Number*
Insurance Company*

Notes

Use the field below to add any additional information you would like present on your final report, such as a passport number.
Type your additional information here:

Patient Consent (OLD)

move to next page
Consent to Testing

I, the above-mentioned patient (parent, if patient is minor), have been informed about the Saliva/Swab test for COVID-19 in detail. By signing this COVID-19 Test Requisition Form, I hereby agree and confirm that the information provided in this form is true and complete. I authorize Neelyx Labs to forward the related information to governmental agencies. I also agree that my clinical data and test results can be investigated and used by healthcare facilities and professionals for further scientific research. I agree to self-isolate until my test is completed. If I test positive, I will adhere to the current government guidelines relating to COVID-19.
Patient Initials (Parent/Guardian if minor)*
HIPAA Email Consent

The Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Most popular email services (ex. Gmail®, Yahoo®) do not utilize encrypted email. When we send you an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. Federal guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email. I UNDERSTAND THE RISKS OF UNENCRYPTED EMAIL AND DO HEREBY GIVE PERMISSION TO THE NEELYX LABS, INC. TO SEND ME PERSONAL HEALTH INFORMATION VIA UNENCRYPTED EMAIL.
Patient Initials (Parent/Guardian if minor)*
Financial & Billing Consent

I agree I am financially responsible for and agree to pay for services, supplies, and use of facilities to provide my medical care and understand Neelyx Labs will charge me at the applicable rate for my Test. If I choose to have my health insurance reimburse Neelyx Labs, I give permission to Neelyx Labs to bill any such insurer and update that information as necessary. I understand that insurance coverage varies and that my insurer may not pay for everything or may pay only part of my bill. I understand that my insurer may deny payment for services that the insurer decides are not “medically necessary”. While Neelyx Labs will take reasonable steps to appeal these denials, I understand that I am responsible for paying for services denied by my insurer.

If I choose to have Neelyx Labs bill my health insurance to pay for my treatment, I assign to Neelyx Labs my rights to receive payment from my health insurer or plan. I also appoint Neelyx Labs as my authorized representative and grant Neelyx Labs limited power of attorney to receive plan coverage information and appeal any rights to payment and healthcare benefits. I agree to cooperate and provide information as needed by Neelyx Labs to establish my eligibility for my insurance benefits. If I claim benefits under Title XVIII of the Social Security Act (Medicare), I hereby certify that the information I provide in applying for payment of such benefits is correct, and I authorize Neelyx Labs to release to the Social Security Administration, its intermediaries or carriers any information needed for this or any related Medicare claim. Even though I may assign my right to receive payment from my insurer, I understand and agree that Neelyx Labs may still require payment directly from me.
Patient Initials (Parent/Guardian if minor)*
Duration of Consent

I understand the preceding consents will expire one (1) year from the date this document is signed. I acknowledge that this consent will apply to all patient encounters with Neelyx Labs prior to the expiration of this consent.
Patient Signature (Parent/Guardian if minor)*

Clear
Date*

MonthDayYear
Date
HIPAA EMAIL CONSENT
The Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Most popular email services (ex. Gmail®, YahooR) do not utilize encrypted email. When we send you an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. In their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The information is available from the Department of Health and Human Services (https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

I UNDERSTAND THE RISKS OF UNENCRYPTED EMAIL AND DO HEREBY GIVE PERMISSION TO THE NEELYX LABS, INC. TO SEND ME PERSONAL HEALTH INFORMATION VIA UNENCRYPTED EMAIL.
Name
Patient Signature (Parent/Guardian if minor)

Clear
Date

MonthDayYear
Date

Patient Consent
Consent to Testing

I, the above-mentioned patient (parent, if patient is minor), have been informed about the Saliva/Swab test for COVID-19 in detail. By signing this COVID-19 Test Requisition Form, I hereby agree and confirm that the information provided in this form is true and complete. I authorize Neelyx Labs to forward the related information to governmental agencies. I also agree that my clinical data and test results can be investigated and used by healthcare facilities and professionals for further scientific research. I agree to self-isolate until my test is completed. If I test positive, I will adhere to the current government guidelines relating to COVID-19.
Consent to Testing*

I consent
HIPAA Email Consent

The Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Most popular email services (ex. Gmail®, Yahoo®) do not utilize encrypted email. When we send you an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. Federal guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email. I UNDERSTAND THE RISKS OF UNENCRYPTED EMAIL AND DO HEREBY GIVE PERMISSION TO THE NEELYX LABS, INC. TO SEND ME PERSONAL HEALTH INFORMATION VIA UNENCRYPTED EMAIL.
HIPAA Consent*

I consent
Financial & Billing Consent

I agree I am financially responsible for and agree to pay for services, supplies, and use of facilities to provide my medical care and understand Neelyx Labs will charge me at the applicable rate for my Test. If I choose to have my health insurance reimburse Neelyx Labs, I give permission to Neelyx Labs to bill any such insurer and update that information as necessary. I understand that insurance coverage varies and that my insurer may not pay for everything or may pay only part of my bill. I understand that my insurer may deny payment for services that the insurer decides are not “medically necessary”. While Neelyx Labs will take reasonable steps to appeal these denials, I understand that I am responsible for paying for services denied by my insurer.

If I choose to have Neelyx Labs bill my health insurance to pay for my treatment, I assign to Neelyx Labs my rights to receive payment from my health insurer or plan. I also appoint Neelyx Labs as my authorized representative and grant Neelyx Labs limited power of attorney to receive plan coverage information and appeal any rights to payment and healthcare benefits. I agree to cooperate and provide information as needed by Neelyx Labs to establish my eligibility for my insurance benefits. If I claim benefits under Title XVIII of the Social Security Act (Medicare), I hereby certify that the information I provide in applying for payment of such benefits is correct, and I authorize Neelyx Labs to release to the Social Security Administration, its intermediaries or carriers any information needed for this or any related Medicare claim. Even though I may assign my right to receive payment from my insurer, I understand and agree that Neelyx Labs may still require payment directly from me.
Financial & Billing Consent*

I consent
Duration of Consent

I understand the preceding consents will expire one (1) year from the date this document is signed. I acknowledge that this consent will apply to all patient encounters with Neelyx Labs prior to the expiration of this consent.
Type your full name to sign (Parent/Guardian if minor)*
Date*

MonthDayYear
Date
The Health Insurance Portability and Accountability Act (HIPAA) was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information. Most popular email services (ex. Gmail®, YahooR) do not utilize encrypted email. When we send you an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. In their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The information is available from the Department of Health and Human Services (https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

I UNDERSTAND THE RISKS OF UNENCRYPTED EMAIL AND DO HEREBY GIVE PERMISSION TO THE NEELYX LABS, INC. TO SEND ME PERSONAL HEALTH INFORMATION VIA UNENCRYPTED EMAIL.
Name
Patient Signature (Parent/Guardian if minor)

Clear
Date

MonthDayYear
Date
Should be Empty:

COVID-19 Test Requisition Form

Clinical Study (with Yale School of Medicine)

PATIENT INFORMATION

Test and Report Method

Form of Identification

Test payment

Credit Card

Healthcare Provider and Insurance

INSURANCE INFORMATION

Insurance Card

Notes

Patient Questionnaire

Patient Consent (OLD)

HIPAA EMAIL CONSENT

Patient Consent