COVID-19 Uninsured Waiver
IF ANY INFORMATION IS FALSE, YOU WILL BE BILLED FOR THE OUT-OF-POCKET COST
PATIENT CONSENT: My signature below constitutes my acknowledgment that the beneﬁts, risks, and limitations of this testing have been explained to my satisfaction by a qualiﬁed healthcare professional. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any other me. I voluntarily agree to the test. If a signature is other than the patient’s signature, print the name. I hereby expressly waive and release any and all claims, now known or hereafter known, against Discovery Health Services/Hummingbird and its oﬃcers, directors, employees, agents, aﬃliates, members, successors, and assigns, on account of injury, death, or property damage arising out of or attributable participation to my participation in the testing, whether arising out of the negligence of Discovery Health Services/Hummingbird or any other release and forever release and discharge the company and all other releases from liability under such claims. I intend my signature to be the required evidence of my assent to completely and unconditionally release all liability for the greatest extent allowed by law. By signing below, I acknowledge that I have read and fully understood all of the terms of this agreement.
PATIENT FINANCIAL RESPONSIBILITY: I understand that I am agreeing to have Discovery Health Services/Hummingbird provide this test at no charge if I can provide evidence to support that I carry no medical coverage at the time of testing. I understand that in order to receive this service for free that my information will run through a system that identiﬁes medical coverage and if it is determined that I had medical coverage as I have already been tested then the ﬁnancial responsibility falls back on me and I will be billed for services at that time. If you are not covered by insurance at the time of your appointment, we will bill HRSA government program through the CARES ACT.