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By submitting this application, I certify that I am electively taking part in the Covid 19 testing program. If this test is being offered through an employment group or other institution, I authorize my results to be released to the designated point of contact for such organization so that they may distribute the results to me. I also understand and consent that my results may be transmitted to me via the email provided in my patient profile above. In addition, only if required by law, I understand that information on my results may be provided to health officials. I understand this voluntary and attest and consent to testing and agree to hold harmless Dynix Diagnostix, and their affiliates, employees, contractors, and volunteers.
I, the undersigned, understand that I am responsible for all co-pays and deductibles and for amounts not covered by insurance. By signing this authorization, I am acknowledging that payment(s) be made on my behalf to Dynix Diagnostix LLC for any services provided to me by Dynix Diagnostix LLC. I also allow the release of any medical information necessary to process this claim.
Otherwise, If I do not have health care coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, I affirm and attest that I qualify as uninsured according to the COVID-19 Uninsured Program in the Coronavirus
Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136).