Rapid COVID-19 Test Insurance and Waiver Policy

INSURANCE WAIVER

I have requested a Rapid Molecular SARS-CoV-2, NAA test today.

I understand and acknowledge the following:

I acknowledge that I am requesting the Abbott ID Now rapid test (“Rapid Test”), which is being made available to me solely for my convenience, surveillance, travel, employment screening, public health purposes, and/or personal reasons that may not qualify the Rapid Test as a covered service under my health insurance plan. I am requesting to obtain the Rapid Test and I am electing to personally pay out of pocket for the Rapid Test and the associated office visit. I have instructed this office not to bill my insurance carrier, if any, for these services. I acknowledge that I will be individually responsible to pay a fee in the amount of $150 for the Rapid Test and associated office visit. I have been informed of the alternative testing options available and understand that these alternatives would likely qualify for coverage under most health insurance plans and may require no out-of-pocket expense; nevertheless, I desire and am electing to obtain the Rapid Test.

If I elected to purchase this rapid test today without a prior telemedicine consultation with AFC Urgent Care’s medical provider, the results of the test will be provided to me without a medical consultation. However, if my test results are positive, I will be entitled to speak via telephone with our medical provider at no extra charge. If I require a further medical consultation beyond that related to my symptoms, I agree to seek additional medical care through AFC’s telemedicine service or with any physician of my choice.

CANCELATION POLICY

I understand and accept that once I authorize my credit card to be charged for booking a rapid Covid-19 molecular test at AFC Urgent Care,  my booking is nonrefundable.

I accept that I will be financial responsible for the full cost of the test which is $150 regardless of whether I show up for my test. I also understand testing appointment slots and supplies are limited.