I authorize to release the information to any third-party payers or its agent to determine if they
would pay for related services.
By signing and dating below, I attest as follows:
1. As of the date of service, I am an Uninsured Individual and not enrolled in a Federal
health care program; or
2. As of the date of service, I am an Uninsured Individual and not enrolled in a group health
plan or health insurance coverage offered by a health insurance issuer in a group or
I further acknowledge that this consent does not establish a patient provider relationship between delware diagnostic labs or
any of its partners and that services are being provided fo the limited purpose of COVID-19 RT-PCR testing. Should follow-up
medical care be required, it is my responsibility to seek it through a primary care physician or health clinic.I also understand
that per state regulations my result will be reported to the appropriate state departments.
THE RESPIRATORY PATHOGEN PANEL ASSAYS ARE NOT 510K CLEARED, BUT MANAGED BY CMS AND FDA UNDER
THE CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) AS A LABORATORY DEVELOPED TEST (LDT). THE
ANALYTICAL PERFORMANCE CHARACTERISTICS OF THESE ASSAYS HAVE BEEN DETERMINED BY DELAWARE
DIAGNOSTIC LABS (DDL). THE ASSAYS HAVE BEEN VALIDATED PURSUANT TO THE CLIA REGULATIONS AND ARE
USED FOR CLINICAL PURPOSES. THE TESTING IS PERFORMED USING A DNA PROBE-BASED REAL TIME RT-PCR
METHODOLOGY.(NUCLEIC ACID AMPLIFICATION TEST (NAAT))
PAYMENTS EXPECTED AT THE TIME OF THE TEST (IF SELF-PAY)
COVID-19 TESTING IS COVERED BY MOST INSURANCE POLICIES. COMPLETE AND ACCURATE INSURANCE INFORMATION IS
REQUIRED FOR PROCESSING.