Employer Covid-19 Back-To-Work Program

EMPLOYER COVID-19 BACK-TO-WORK PROGRAM

Patient Information
Insurance Info
Medical Triage
Medical Consent & Release Form

Select your visit type:

Please reserve your spot on Wednesday, limited spots are available on Monday.

Employer Name:

Employer Address:

Address

City

State

Zip Code

PATIENT INFORMATION

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile:

Social Security #:

Date of Birth:

Marital Status:

Single

Married

Divorced

Widow

Other

Email:

CONTACT INFORMATION (IN CASE OF AN EMERGENCY WHO SHOULD BE NOTIFIED)

First Name

Last Name

Relationship:

Phone/Mobile:

As a courtesy, your medical notes will be faxed to your primary physician, unless you indicate here:

Do you have Health Insurance?

Yes

COVID-19 UNINSURED PROGRAM ATTESTATION

First Name:

Last Name

Date of Birth:

Upload Driver License or Government Issued Photo ID (JPG and PNG format). Max 10MB.

Choose File

SSN:

As part of the FFCRA, Paycheck Protection Program and Health Care Enhancement Act, and CARES Act, the U.S. Department of Health and Human Services (HHS) will provide claims reimbursement to health care providers for testing uninsured individuals for COVID-19 and treating uninsured individuals with a COVID-19 diagnosis.

I attest that:
• I am uninsured.
• I do NOT have health care coverage (individual, employersponsored, Medicare, or Medicaid).
• No other payer will reimburse for COVID-19 testing and/or treatment/care.
• My visit today is for COVID-19 symptoms, known exposure or suspected exposure. Any charges incurred that are not covered by this program are my financial responsibility.
• If I enroll in any insurance plan, whether commercial, Medicaid or Medicare and the effective date is backdated to cover this particular visit, I agree to notify CBS Labs, LLC of such coverage.

I authorize CBS Labs, LLC to bill me for amounts determined by HRSA/Medicare to be my responsibility, or if my claim is denied, all amounts that CBS Labs, LLC is authorized by law to bill me. I assign my insurance benefits to the provider listed above.

Signature of Patient, Parent, Guardian or Personal Representative

Please Sign Here

Date

INSURANCE INFORMATION (MUST BE COMPLETED ENTIRELY)

Primary Insurance:

Name of Insured:

Date of Birth:

Policy #:

Group #:

Relation to Patient:

Upload Insurance card (Front & Back) JPG and PNG format. Max 10MB.

Choose File

Upload Driver License or Government Issued Photo ID (JPG and PNG format). Max 10MB.

Choose File

Upload Prescription (JPG and PNG format). Max 10MB.

Choose File

ASSIGNMENT, RELEASE, AND FINANCIAL RESPONSIBILITY

I authorize release of medical information to process claims to my insurance company and request that benefits be paid directly to FastCare, LLC. I understand and agree that regardless of my insurance sources, I am ultimately responsible for the balance of my account for any professional services rendered. I authorize the use of my signature on all insurance submissions. I have read all the information on this sheet and certify this information to be true and correct to the best of my knowledge. I ALSO HEREBY CONSENT AND GRANT PERMISSION TO FASTCARE, LLC AND ITS MEDICAL STAFF TO VIEW AND DOWNLOAD MY PRESCRIPTION HISTORY FROM EXTERNAL SOURCES.

Signature of Patient, Parent, Guardian or Personal Representative

Please Sign Here

Date

Print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

COVID-19 TRIAGE QUESTIONNAIRE

Your Height:

Your Weight:

1. In the last 7 days have you had fever, shortness of breath, cough, loss of sense of smell or taste?

Yes

2. Have you been in contact with Covid-19 positive person?

Yes

3. Are you currently taking ANY medications? If so, please list which ones.

Yes

4. Are you allergic to any medications? If so, please list them.

Yes

5. Do you have any pre-existing conditions? (Such as diabetes, high blood pressure, asthma.) If so, please list them.

Yes

6. Have you had any past surgeries or hospitalizations? If so please list them.

Yes

7. Are both of your parents alive? Do they have diabetes, high blood pressure or heart disease?

Yes

8. Do you have any children? How many boys, how many girls.

Yes

9. Do you smoke cigarettes?

Yes

10. Are you currently pregnant or breast feeding?

Yes

CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) / RELEASE OF RECORDS TO EMPLOYER

Section A:

Patient Consent

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile:

Social Security #:

Section B:

Please read the following information:

Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health information to carry treatment, payment activities, and health operations, and to your employer for workers compensation purpose if needed.
Notice of Privacy Practices: You have the right to read our Notice of Privacy practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of our protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected health information that we maintain. You may obtain a copy of our notice of Privacy Practice, including any revisions in our Notice, at any time by contacting our office at:

20601 E. Dixie Highway, Suite 340, Aventura, Fl. 33180 or 825 Arthur Godfrey Road, Suite 100, Miami Beach, FL 33140
Phone#: (786) 923-4000

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of revocation submitted to the contact person listed above. Please understand the revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this consent.

I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

I authorize the release of my Covid-19 test results to my employer, I understand that the medical records are confidential and cannot be disclosed without specific written consent of the person to whom they pertain, or as permitted by law, I further understand that once released, the record custodian, or its employees have no responsibility or liability that may arise regarding any aspect of this authorization. This authorization is effective as of the date of signing and may be revoked in writing to FastCare at any time.

Signature of Patient, Parent, Guardian or Personal Representative

Please Sign Here

Date