Covid-19 Rapid Antigen – Walkin

Patient will get a phone call from a nurse practitioner for an audio-visual televisit.
Please answer the phone call to get the results via email.
I consent to Televisit

Do you have symptoms?

Disclaimer: I authorize Chandra Diagnostics Cardiology & Apex Medical Research and its affiliates to leave messages regarding my health/test results and or billing issues on my voicemail.
RELEASE OF INFORMATION:
I hereby authorize the release of any medical records or other information necessary to process the claim by Chandra Diagnostics Cardiology. I authorize the payment of medical benefits to service providers.
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION:
I request that payment of authorized medical benefits is made on my behalf directly to the Chandra Diagnostic Cardiology provider of service(s) furnished to me. I authorize Chandra Diagnostic Cardiology to release any medical information to my health insurance carrier and/or its legitimate agents, partners or affiliates that is necessary to bill related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards and for medical research or clinical research. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employers’ or group health insurance plan, directly to Chandra Diagnostics Cardiology. I hereby authorize photocopies of this form to be valid as the original.
ELECTRONIC HEALTH RECORD:
Chandra Diagnostics Cardiology has system-wide electronic medical record system that is available to caregivers on a “need to know” basis, to share information about patient care provided in the hospital, outpatient or physician office settings or for medical research. Confidentiality of records is maintained pursuant to relevant HIPAA and other governmental and regulatory standards. Patient care summaries are automatically sent to designated Chandra Diagnostics Cardiology providers and other physicians for coordination of care. Chandra Diagnostics Cardiology and/or the attending physician may furnish and release to federal and state healthcare oversight agencies, or upon written request, to all insurance companies or their designated representatives any information with respect to my treatment, including copies of my medical record.
AUTHORIZATION RIGHTS:
I have the right to revoke this authorization at any time by writing to Chandra Diagnostics Cardiology except to the extent that action has already been taken in reliance on this authorization. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information disclosed by the recipient and this redisclosure may no longer be protected by federal or state law. This authorization will expire after eleven years from the date of signature.