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

Vehicle Information

License Plate Number

State

Make

Model

Take Photo of Vehicle License Plate

Schedule a Test*

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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 *

Country *

Zip Code *

County

Email *

I decline To Provide Email

Phone Type *

HomeMobile

Is Opt-in Text Messages

Phone No *

I decline To Provide Phone No

Gender * MaleFemaleUnknown

Passport No

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

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 PayCommercial
MedicareMedicaid
Other Ins.Worker's Comp DOI
AutoCovid 19 HRSA
Client Bill

Illness/Accident Date

Month: Day: Year:

Accident Type

Accident State

Bill to:

InsurancePatient Self-Pay

Relationship to Insured:

Self	Spouse
Dependent	Other

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Subscriber Name

Policy Holder DOB *

Month:Day:Year:

Primary Insurance Provider

Insurance Name

Insurance Address

Insurance City

Insurance State

Insurance Zip Code

Primary Policy ID *

Primary Group ID

Insurance Phone #*

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PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

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

I hereby consent to Gather Lab, LLC performing the designated test(s) on the DNA sample provided by me. My signature below constitutes my acknowledgment that Read more

I hereby consent to Gather Lab, LLC performing the designated test(s) on the DNA sample provided by me. My signature below constitutes my acknowledgment that I have been informed, by a physician or other licensed practitioner, of the benefits and limitations of this testing. I also consent to Gather Lab, LLC - or its reference lab - to providing de-identified information of a statistical nature to accrediting agencies and Gather Lab, LLC reserves the right to use such anonymous information in compliance with applicable regulations. Assignment of Benefits: I hereby authorize Gather Lab, LLC 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 of my account and any and all charges associated with its collection. 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 Gather Lab, LLC or its affiliates to release any information required for billing purposes. I acknowledge Gather Lab, LLC 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 Gather Lab, LLC within 30 days.

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