One Love

Patient Requisition Form - Covid-19 Testing

ONE LOVE LABORATORY, 4922 ALBEMARLE RD CHARLOTTE, NC 28205, CLIA ID: 34D2121983

Account

@php use App\Models\Organization; if (isset(request()->org)) { $org = Organization::find(request()->org); // dd($org->org_id); } if (isset(request()->orgCode)) { $org = Organization::where('org_code', request()->orgCode)->first(); // dd($org); } @endphp

@if ($errors->has('organization'))

@endif

{{--

Account State

orgState ? 'readonly' : '' }}>

--}}

Site

Name*

{{-- First Name --}} @if ($errors->has('fname'))

@endif

{{-- Last Name --}} @if ($errors->has('lname'))

@endif

Gender*

Male

Female

Prefer not to respond @if ($errors->has('gender'))

@endif

{{--

Ethnicity*

@if ($errors->has('ethnicity'))

@endif

--}}

Ethnicity*

@if ($errors->has('ethnicity'))

@endif

SSN

@if ($errors->has('ssn'))

@endif

Date Of Birth *

@if ($errors->has('dob'))

@endif

Email*

@if ($errors->has('email'))

@endif

Phone #*

@if ($errors->has('phone'))

@endif

Home Address*

@if ($errors->has('address_one'))

@endif

@if ($errors->has('address_two'))

@endif

@if ($errors->has('city'))

@endif

@if ($errors->has('state'))

@endif

@if ($errors->has('zipcode'))

@endif

Are you 18 or older?*

Yes

Take Photo of Front of Picture ID *Required for all adults 18 and older

@if ($errors->has('frontPic'))

@endif

Take Photo of Back of Picture ID *Required for all adults 18 and older

@if ($errors->has('backPic'))

@endif

DL/State ID Number

@if ($errors->has('dl_or_state_id'))

@endif

DL/ID Issuing State

@if ($errors->has('dl_or_id_issuing_state'))

@endif

Do you have Health Insurance*

Yes

Insurance Type

{{-- --}} @if ($errors->has('insurance_type'))

@endif

Policy Number

@if ($errors->has('policy_id'))

@endif

Group Number

@if ($errors->has('group_id'))

@endif

Take Photo of Front of Insurance Card

@if ($errors->has('insuranceFrontPic'))

@endif

Take Photo of Back of Insurance Card

@if ($errors->has('insuranceBackPic'))

@endif

Relationship to Patient

SELF

SPOUSE

CHILD

OTHER

@if ($errors->has('relationship_to_patient'))

@endif

Test Selection and Diagnosis Code Selection

Buccal Swab @if ($errors->has('buccal_swab'))

@endif

{{--

Nasal Swab @if ($errors->has('nasal_swab'))

@endif

Saliva Swab @if ($errors->has('saliva_swab'))

@endif

Nasopharyngeal Swab @if ($errors->has('nasopharyngeal_swab'))

@endif

--}}

COVID 19 SARS-COV-2 by RT-PCR

Z03.818

Encounter for observation for suspected exposure to other biological agent ruled out

For cases there is a contact for possible COVID-19 exposure

@if ($errors->has('Z20828'))

@endif

COVID-19 and HIPAA
During the COVID-19 national emergency, which also constitutes a nationwide public health emergency, the HHS Office for Civil Rights (OCR) has provided guidance that helps explain how the HIPAA Privacy Rule allows patient information to be shared in the outbreak of infectious disease and to assist patients in receiving the care they need. The district will follow federal guidelines relating to HIPAA and Protected Health Information (PHI).

Consent/Insurance Release: I, the undersigned, understand and grant permission to One Love Laboratory to bill my insurance for laboratory services provided. I understand that the services provided may not be covered by my insurance. I further understand that I am not responsible for co-pays, deductibles, and any amount not covered by my insurer. By signing below, I acknowledge that payment may be made on my behalf to One Love Laboratory. I hereby authorize the ordering physician and/or clinic to disclose any personal or medical information that may be needed to process claims related to services rendered by One Love Laboratory and its affiliates. I understand that my records may be protected under 42 CFR Part 2, under which I may revoke my consent at any time except to the extent that action has been taken in reliance on it, and that in any event, this consent expires six (6) months after the date of program discharge. I consent for and the Health Department to receive a copy of my results.

Sign

@if (isset(request()->org) || isset(request()->orgCode)) @endif

Patient Requisition Form - Covid-19 Testing

Account

Account Code

Account State

Site

Sub-Account Code

Sub-Account State

Name*

Gender*

Ethnicity*

Ethnicity*

SSN

Date Of Birth *

Email*

Phone #*

Home Address*

Are you 18 or older?*

Take Photo of Front of Picture ID *Required for all adults 18 and older

Take Photo of Back of Picture ID *Required for all adults 18 and older

DL/State ID Number

DL/ID Issuing State

Do you have Health Insurance*

Insurance Type

Policy Number

Group Number

Take Photo of Front of Insurance Card

Take Photo of Back of Insurance Card

Relationship to Patient

COLLECTION DATE (Today's Date)*

COVID 19 SARS-COV-2 by RT-PCR

Sign