Empower Portal

Desert Mirage High School Test Facility

PATIENT INFORMATION

First Name

Last Name

DOB

SSN

Phone

Sex

Race

Ethnicity

Street Name

Apartment Number

City

State

Zip Code

E-mail

Employee/Student Id Number

ID INFORMATION

Type of Document

ID Number

Expiration Date

Upload your photo ID

Issuance Place

INSURANCE INFORMATION

Bill To (Please select one)

Insurance Company

Member ID/Policy#

Group#

Member / Subscriber Name

Relationship

COVID-19 Testing Consent Form:
I voluntarily consent and authorize Dalrada Health, its affiliates, and any of their employees, agents, or representatives to administer, collect, process, analyze, and bill my COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasal swab, oropharyngeal swab, or other recommended collection procedure, or in the alternative, an instructed self-collected or observed collected specimen via similar means. I certify that I will provide an unadulterated specimen and will follow all instructions provided. I acknowledge that I am not creating a patient-healthcare relationship with Dalrada Health, and/or Ordering Physician and that any questions or required to follow up shall be my responsibility to arrange with my physician.
I authorize a HIPAA release and waiver, and by doing so, Dalrada Health may release the results of this testing to the authorized healthcare provider, facility, employer, sponsoring organizations, and/or to my designated email or phone number that I have provided. I understand that by submitting this COVID-19 test request with my associated health insurance information or by requesting payment from governmental funds set aside for COVID-19 services provided to the uninsured, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, healthcare operations. I hereby irrevocably assign to Dalrada Health and its affiliated laboratories all benefits under any policy of insurance indemnity agreement or any collateral source as defined by statute for services provided. This assignment includes all rights to collect benefits directly from my insurance company.

I have read and agree to the PATIENT ACKNOWLEDGMENT AND CONSENT.

PATIENT SIGNATURE

Date