Covid Testing Registration

THIS FORM BELOW IS USED ONLY TO REGISTER FOR TESTING AT AN UPCOMING TESTING SITE.

Moss Point Visionary Circle (MPVC) is a national health care provider (NPI #1184241812). The Covid-19 testing project is supervised by a state licensed medical doctor and all tests are administered by certified advanced healthcare professionals. MPVC is a 501(c)(3) non-profit organization, dedicated to assisting those affected by tragedy. (CLIA #25D2191057)

IS THERE A COST?
The testing is open to anyone. There are no insurance requirements to be tested. This service is provided to Low Income and Uninsured residents free of charge. However, if you do have insurance, please bring your insurance card.

THERE ARE NO OUT OF POCKET EXPENSE FOR ANYONE. THERE IS NO COPAY, NO SLIDING SCALE, NO BILL.

Test results will be provided on site within 15-20 minutes.

WHAT DO I BRING TO THE TEST SITE?
When you have confirmation of your registration to the email or phone number you provided, please make sure to bring:

an official form of identification
your social security number
and proof of health insurance, if you have coverage

* Let us know below if you do not currently have health insurance.

HOW DO I REGISTER?
Please complete as much information as you can in the form below.
Once submitted, please look for a follow-up in email to set up the test time and closest location..

First Name

Middle Initial

Last Name

Date of Birth

Gender

Male Female Other

Race

Street Address

Street Address #2

City

State

Zip Code

Cell Phone

Alternate Phone Number

Health Insurance

CONSENT STATEMENT: By clicking below, I agree to the following: Consent to Treat: I consent to and authorize the physicians, nurses and other healthcare providers at MPVC to perform CoVidD-19 testing. I understand that there are some risks with all medical procedures, and I release MPVC’s liability. Assignment of Benefits/Payments for Services: I hereby give permission to MPVC to release any medical information to Medicare, Medicaid, or any insurance company that is needed to receive payment for CoViD-19 testing services. Release of Information I consent to the release and use by MPVC of my protected health information to the extent permitted by law to and for the following: • To a healthcare provider being advised or consulted in connection with my treatment or care • To a health plan, insurer, third party payer, third party administrator or other organization providing me with health benefits, for the purposes of claims payment and benefit determinations, fraud investigations, or quality of care studies or reviews • To a person or organization in connection with MPVC’s healthcare operations. These operations may include interdisciplinary care conferences, quality improvement activities, performance evaluations, business management and other related activities. • To leave medical, billing or scheduling information on this voice mail/answering machine number: Patient Rights and Privacy Practices: I acknowledge that I have reviewed MPVC’s Notice of Privacy Practices, which describes how medical information about me may be used and disclosed and how I can get access to this information. I am aware that I may obtain a copy of the Notice of Privacy Practices upon request at any time. Financial Agreement: CoViD-19 testing is provided at no cost to the patient. We rely on the fees paid by your insurance carrier and/or the federal government to offer this service. For Patient with No Insurance: I understand that MPVC will bill the federal government for CoViD-19 testing services. For Patients with Insurance: I understand that MPVC will bill my insurance carrier first for CoViD-19 testing services, and any remaining balance will be billed to the federal government. My signature here means I have read this information and understand it. This consent is valid until revoked in writing

Yes, I Agree to the Above Consent Statement

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