Coronavirus Pre-Screening Authorization Form

If you are symptomatic or, you have been in direct contact with an individual that is positive, your COVID test can be billed through your insurance.  If you do not have insurance, you may qualify for coverage under the CARES Act. 

To get started, you will “schedule an appointment” through the On Demand Occupational Medicine web portal.  Provide the details about your insurance provider, including the policy number, group ID number, and if applicable, the primary insurance holder’s name, address, phone number, and date of birth.

When you arrive at On Demand you will provide a form of identification and receive an exam from an On Demand physician, physician assistant or a nurse practitioner.

A trained healthcare professional will guide you through the swabbing process. The swab collection may be performed using a nasopharyngeal swab.

Nasopharyngeal Swab: This method of testing is performed by having you tilt your head back while a trained healthcare member inserts a sterile cotton swab into your nostril towards the back of your nose. The swab will be inserted to a depth about the distance from your outer nose to the outer opening of the ear. Once inserted, it will be held in place for a few seconds then slowly removed with mild rotation. This may cause temporary discomfort.

Your sample will be coded and associated with the data you provided in your questionnaire.

Your sample will be express shipped to a clinical laboratory to determine if your sample is either positive or negative for SARS-CoV2.

Within 24-72 hours your lab results will be provided directly to you via email, text, phone call or through an app or web portal. The testing result may take a few days and results will be returned to you when available. Weekends and holidays affect these hours.

Coronavirus Pre-Screening Authorization Form

Summary

This authorization form (the “Authorization Form”) refers to “you” as the person whose information and sample is being provided for the Covid-19 test, or if you are the parent, guardian or otherwise legally authorized to sign this form on behalf of another person (the “Legal Representative”) then “you” refers to you as the Legal Representative, or the person receiving the Covid-19 test, as the context requires. Important requirements that apply for minors are described below.

Availability of Testing for Minors

For minors, it is required that you, The Legal Representative:

  • Agree to this form on behalf of the minor, which authorizes administration of the test to the minor and also use of the minor’s personal and health information as described in this Authorization Form;
  • Accompany the minor to the testing facility;
  • Support administration of the test to the minor as described in this form or requested at the time of testing; and
    Provide any reasonably necessary support before or after testing.

We want to assure availability of testing to minors. These requirements will help keep minors safe and protect their legal rights. Tests for minors will therefore only be provided when all of these requirements are met.

General Eligibility for Testing

We apply eligibility requirements for all program participants. To understand whether you are eligible for a test through this program, your contact information, demographics, and survey responses will be collected. These data are also shared to help with scheduling and providing tests. Your test results will also be collected for the purposes of this public health program. All data that we collect from you will be protected, but it may be shared with people and organizations that help run this public health program.

This means that data about you (including contact information, survey responses, health insurance information, and test results) may be shared with third parties. These include the entity administering the program and its contractors, Verily and its contractors, individuals and organizations that assist with the testing program (like healthcare professionals and clinical laboratories) and public health authorities, which may include federal, state, and local health authorities. Please read this in its entirety for further information.

Coronavirus Test Pre-Screening
Age 10-15: Parent or legal guardian needs to fill out form and accompany patient to visit. Age 16-17: Parent or legal guardian needs to fill out form.
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Have you experienced any of these symptoms? (Select any that apply)
Do you have any of the following medical conditions? (Select any that apply)
If applicable, are you currently pregnant?
Do you work in health care?
In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient? (e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected)
Do you work in a special setting where the risk of COVID-19 transmission may be high? (This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes)
Are you a resident in a special setting where the risk of COVID-19 transmission may be high? (This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes)
Have you been prioritized for testing by a medical professional?
Is this your first time taking the COVID-19 test?
Do you carry a health insurance policy? *
By checking this box, I understand I will be evaluated by a healthcare professional at my appointment. *
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