Palm Beach County BOCC

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
(THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED)
Information*
Please enter information of those taking Quest and Labcorp based Coronavirus Test.
First Name
Last Name
Date of Birth
Phone Number
 

Sending Records From

NMS Management Services, Inc/Quest
Address: 2901 S. Congress Ave
Phone: 561-967-8884
Fax: 561-932-1597
City: Palm Springs
State: Florida
Zip: 33461

Sending Records To

Palm Beach County BOCC
Address: 100 Australian Ave. #200
Phone: 561-233-5432
City: West Palm Beach
State: Florida
Zip: 33406
Email: [email protected] & [email protected]

Authorizations

Type of Medical Request*
The laboratory is required to report all testing performed to the department of health.
I authorize the release of my COVID-19, Corona Virus , Antibodies Test Results, whether negative or positive to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.*
You acknowledge and understand that NMS shall not be liable and shall be held harmless for any discomfort or any other derivative consequence of the process of specimen collection. It is understood that the process of collecting the specimen itself may involve an invasive process that can result in reflex reaction by the subject during the collection process. Further, it is understood that NMS is not responsible for the result or any consequence imposed upon the subject due to the result of the testing.*
Disclaimer*

Your Information

Your Name*
Address*
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