PBSO/Cigna Onsite Health - NMS Management Services

(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

PBSO/Cigna Onsite Health – Teresa Paterson / Fred Thomas
Address: 3228 Gun Club Rd.
Phone: 561-967-8884
City: West Palm Beach
State: Florida
Zip: 33406
Email: [email protected] / [email protected]

Authorizations

Type of Medical Request*

All Laboratory Results

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.*

Yes

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.*

Yes

Disclaimer*

I agree to the following disclaimer.

The COVID-19 Immunity (IgG) test does not directly detect the virus and should not be used to diagnose or exclude COVID-19 infection. A negative result may occur if you are tested early in your illness and your body hasn’t had time to produce antibodies to infection. Even if your COVID-19 Immunity (IgG) test is positive, that does not mean you are immune to COVID-19. If you suspect you may be infected with COVID-19, you should talk to your healthcare provider, and direct testing for the virus, COVID-19, should be performed.

Your Information

Your Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Copy of Driver's License*

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