Covid-19 Vaccine Form

Parent and Insurance Information

Last Name *

First Name *

Middle Name

Date of Birth *

SSN/Passport/Drivers License/State ID *

Mailing Address

City

State

Zip

Telephone or FAX (for results) *

Email (for results) *

Gender

Female

Male

Others

Are you feeling sick today?

Yes

No

If Yes, what sickness?

Fever

Chills

Cough

Headache

Sore throat

Shortness of Breath

Reason for Testing

Exposure

Symptoms

Work

Travel

Did you receive a Covid-19 Vaccine

Johnson & Johnson

Moderna 1 Dose

Moderna 2 Dose

Pfizer 1 Dose

Pfizer 2 Dose

None

Relationship to Insured

Self

Spouse

Child

Policy ID Number

Group Number

Reporting Method (Select One)

email

fax

pick-up

Upload Drivers License *

Upload Insurance Card

Car Make

Car Color

Select Test

Rapid Test - Results in 15 minutes, $55. If this one is chosen, no insurance needed (do not ask for it)

RT-PCR test, results in 48-72 hours billed to insurance.

By signing this document, I accept financial responsibility and am aware of the testing fees. I authorize Reliance Diagnostics, LLC to release information received including, without limitation, medical information, which includes laboratory test results, to my health plan/insurance carrier and its authorized representatives. I understand Reliance Diagnostics, LLC maybe filing an out of network claim to my insurance company on my behalf. I further understand my health plan/insurance carrier may not approve and reimburse for testing in full due to coverage limits, benefits exclusions, lack of authorization, medical necessity or otherwise. My signature indicates I acknowledge and accept full financial responsibility for all services rendered at Mymedpasstraining.com

Patients Signature *

American Indian or Alaska Native	Caucasian	Hispanic or Latino	Asian
Pacific Islander	Black or African	Others