COVID-19 Test Registration
Fields marked with
*
are required.
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AFGHANISTAN
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SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS
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THAILAND
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VIET NAM
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WALLIS AND FUTUNA
WESTERN SAHARA
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Your Race
Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Unknown
Your Ethnicity
Select
Hispanic
Non-Hispanic
Unknown
What tests are you requesting?
COVID-19 Serum IgM Testing
COVID-19 PCR Testing
COVID-19 Antigen Testing
Password to View Report
(6 to 8 alphabets and numbers, no special symbols)
Photo ID
(e.g. Passport picture page, driver's license, Max file size 3MB. Allowed file types JPG, PNG & PDF)
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How do you want to pay?
Insurance
Credit Card on Site
Cash on Site
Insurance Card Front
(Max file size 3MB. Allowed file types JPG, PNG & PDF)
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Insurance Card Back
(Max file size 3MB. Allowed file types JPG, PNG & PDF)
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Are you pregnant?
No
Yes
Is this your first COVID-19 test?
Yes
No
Are you exhibiting COVID-19 symptoms?
Yes
No
Start Date
Symptoms
Additional Information
Patient Privacy Notice and Acknowledgement
We are required by law to provide you this notice about how we plan to use and share your health information. Based on your request for testing, we plan to use and share your health information provided in compliance with the HIPAA guidelines. It is your right to have your personal health information to be used for purposes only for which it is intended and to be shared to fulfill your request accordingly. The Privacy Rule allows provider to use and disclose protected health information. Your permission (authorization) is necessary before your health records are shared for any other reason.
The law requires us to ask you to state in writing that you received the notice. But you are not required to sign. Signing does not mean that you have agreed to any special uses or disclosures (sharing) of your health records. Refusing to sign the acknowledgement does not prevent a provider or plan from using or disclosing health information as HIPAA permits but we must keep a record this fact.
You have your privacy rights, including the right to complain to Health and Human Services and to the organization if you believe your privacy rights have been violated. For details visit the HHS website. You may view this policy at our website,
www.GoPathLabs.com
any time.
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