Note: All information with a red asterisk ( * ) must be completed

Vehicle Information

License Plate Number

State

Make

Model

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Patient Information

Patients *

First Name *

Middle Name

Last Name *

Patient DOB *

Month: Day: Year:

Minor

Address 1 *

Address 2

City *

State *

Zip Code *

County

Email *

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Phone Type *

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Is Opt-in Text Messages

Phone No *

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Gender * MaleFemaleUnknown

Patient Ethnicity * African AmericanAsianCaucasian
HispanicOther

Weight (lbs.)

Height

Social Security Number

DL/State ID

Clinical Information *

History of recent abnormal Pap smear/cervical biopsy
History of solid organ or marrow transplant
Elevated sexual history risk
History of collagen-vascular or autoimmune disorder
History of recent chemotherapy for cancer
History of diabetes mellitus
Hematologic neoplasm (leukemia, lymphoma)
Current history of chronic opioid therapy
Immunocompromised patient
Recent first-order contact with known infectious person
Malnutrition (low protein/albumin/prealbumin, low immunoglobulins, vitamin deficiencies, etc...)
Corticosteroids other immunosuppressive agent(s)
None
Other

Pregnant YesNo

Estimated Delivery Date

Testing Option

COVID Questionnaire

Date of covid exposure*

YesN/A

Select date of covid exposure*

Month: Day: Year:

Date of covid symptoms*

YesN/A

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Month: Day: Year:

Are you vaccinated*

YesNo

Select date of last dose*

Month: Day: Year:

What are the symptoms*

Sore throatDifficulty breathingFeeling more tired than usualChanges in sense of smell
CoughHeadachePainN/A
Other Symptoms

Specify:

Do you have medical problems*

YesNo

Enter medical problems*

Physician Order not Required

Physician Information

Physicians *

Medical Necessity

Signs and Symptoms

No of Days.

R06.02:Shortness of Breath
R50.9:Fever, unspecified
R51:Headache
R05:Cough
R68.83:Chills
R52:Muscle Pain
J02.9:Sore Throat
R43.8:New Loss of Taste or Smell/or Both
Z20.828:Suspected Exposure
Z03.818:Encounter for Observation
U07.1:COVID-19 Identified(only if previously tested positive)

Shortness of breath (R06.02)

Fever unspecified (R50.9)

Headache (R51)

Cough (R05)

Chills (R68.83)

Muscle Pain (R52)

Sore Throat (J02.9)

New Loss of Taste or Smell/or Both (R43.8)

Suspected Exposure (Z20.828)

Encounter for Observation (Z03.818)

COVID-19 Identified(only if previous positive) (U0701)

Billing Information

Please Provide Insurance Type *

Self Pay/Non-InsuredInsurance
MedicareMedicaid
Other Ins.Worker's Comp DOI
AutoCovid 19 HRSA
Direct PayEmployee-courtesy
Client Bill

Illness/Accident Date

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Accident Type

Accident State

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InsurancePatient Self-Pay

Relationship to Insured:

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Dependent	Other

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Subscriber Name

Policy Holder DOB *

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Primary Insurance Provider

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Primary Policy ID *

Primary Group ID

Insurance Phone #*

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PATIENT SIGNATURE:

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By selecting the Add Signature button, I attest that I approve of this digital signature

I hereby consent to Provista Diagnostics, Inc performing the designated test(s) on the sample provided by me. I also consent to Provista Diagnostics Read more

I hereby consent to Provista Diagnostics, Inc performing the designated test(s) on the sample provided by me. I also consent to Provista Diagnostics, Inc, all providers, affiliates, and/or ancillary personnel of Provista Diagnostics, Inc to providing de-identified information of a statistical nature to accrediting agencies and Provista Diagnostics, Inc reserves the right to use such anonymous information in compliance with applicable regulations. I acknowledge that the sample provided by me may be used for internal research and validation purposes ONLY if all ordered testing requirements are fulfilled and the results have been released to HCP and patients. All steps will be taken to ensure PHI remains secure.
Assignment of Benefits: I hereby authorize Provista Diagnostics, Inc or its affiliate to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment in the event my insurance does not pay for the testing provided. I hereby authorize my insurance company to pay the company directly for services rendered.
Appeal Authorization: In the event of an underpayment or denial by my insurance carrier, I hereby authorize the company or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim including any rights to penalties and attorney’s fees provided under LRS §22:1821(A) and other state laws as may be applicable. This authorization shall remain valid until the charges for the orders on this form are paid in full.
Donor Signature: I certify that I provided my specimen to the specimen coordinator, that I have not adulterated it in any manner, each specimen used was sealed in my presence, and that the information provided on this form and on the label affixed to each specimen is correct. I authorize the release of the results to the ordering clinician, authorized client/representative, or prescribing/attending physician. I authorize Provista Diagnostics, Inc or its affiliates to release any information required for billing purposes. I acknowledge Provista Diagnostics, Inc or its affiliates may be an out of network provider with my insurer. I agree that if my insurance provider sends payment directly to me, I will endorse the insurance check and forward to Provista Diagnostics, Inc within 30 days.
USE AND DISCLOSE PHI I hereby consent and authorize Provista Diagnostics, Inc to use and disclose my health information, which includes all or any part of my health records, including drug or alcohol treatment information, genetic, genetic counseling and genetic testing information, and any other information concerning my diagnosis or treatment, as well as demographic information, by and to its workforce members and to health care professionals, insurance companies, medical facilities, physicians and vendors, or who may become involved, with my care and treatment, the payment for my care and treatment. In addition, I understand Provista Diagnostics, Inc may release my health information as required by law or by a court order.

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