VIP COVID-19 TESTING – PPOA LAB TEST

CALL
813-397-3222

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Date of Birth*
Race*
Ethnicity*
3. Finalize

I understand that by submitting the above personal as well as health insurance information, 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, and/or health operations and as otherwise described in our privacy policy*
I give my consent
I understand that by submitting the above personal as well as health insurance information, 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, and/or health operations and as otherwise described in our privacy policy