If you checked "Exposure" above, on what date were you exposed to someone with COVID-19?
If you checked "Other" above, please provide details.
SS# *
Cell Phone *
Email *
Street Address *
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Primary Insurance
ID#
Group#
Subscriber Name
Secondary Insurance
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Group#
Subscriber Name
I will receive AccessMD Urgent Care alerts via text, email, and patient portal. *
I understand a Negative Rapid COVID-19 test does not preclude infection, is presumptive, and should be confirmed with lab-based RTPCR testing if I have had known exposure, are exhibiting symptoms, or otherwise clinically indicated. *
I understand that if I have a Positive Rapid COVID-19 test, have had a known exposure, and/or are exhibiting symptoms, it is recommended by AccessMD that I follow-up with a provider visit for further evaluation and management. *
I authorize the administration and cost of all medical procedures, test, x-ray, and medication for myself and my dependents. *
IF NO INSURANCE: Apply for HRSA COVID-19 Uninsured Program at coviduninsuredclaim.linkhealth.com or see the front desk for more information. *
INSURANCE: Assignment of Benefits: I authorize payment directly to AccessMD Urgent Care for all benefits otherwise payable to me. I understand that I am financially responsible for all charges not covered by insurance. I authorize AccessMD Urgent Care to submit claims to my insurance carrier as well as medical records required to evaluate these claims for payment. *
