COVID-19 EREQ

Patient Information

Insurance Type

Provider Information

COVID-19 Tests Select the order code(s) for this requisition


Virus Detection:
U0003 - SARS-CoV-2

DX Code(s):
Contact with and (suspected) exposure to COVID-19 (Z20.822)
Custom State Required Questions


Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown

Yes No Unknown

Yes Unknown Prefer not to answer
Yes No Prefer not to answer
Yes No Prefer not to answer
Yes No Prefer not to answer

Allow us to email you when results are ready

You agree that Northwest Labs may send automated messages to the email that you provided above. Messages may include limited health information that will be encrypted. Participation is not required in order to receive services. Your password will be your 4 digit year of birth.
I certify that I have voluntarily provided a fresh and unadulterated specimen for analysis by Northwest Laboratory. I also acknowledge that the information provided on this form and the specimen label is completely accurate. I authorize Northwest Laboratory to release the results obtained from this testing to the authorized ordering physician &/or Healthcare facility. In addition, I authorize payments by my insurance plan to be billed and to be paid directly to Northwest Laboratory for services rendered. I acknowledge that Northwest Laboratory may be an out-of-network provider with my insurer. I am also aware the in some circumstances my insurer will send the payment directly to me. I agree to endorse insurance check and forward it to Northwest Laboratory within 30 days of receipt. Failure to do so may result in account being forwarded to Collections and reported to a Credit Bureau. I certify & hereby acknowledge that as the authorized ordering Physician/Practitioner I will only order tests that I believe are necessary for each of my patients. Upon request from Northwest Laboratory, Provider agrees to produce all documents necessary to provide the insurance company with proof of medical necessity, including follow-up requests from the insurance company or other third party payer. This includes, but is not limited to, medical notes, patient records, and other documents beyond the request for lab work. These additional documents shall be produced once Northwest Labs requests such documents. Provider understands that the patient agrees to release his/her medical records to Northwest Laboratory when Provider signs the requisition form. Provider has made the patient aware of his/her privacy rights and the need to transmit certain information to additional providers as part of the patient's ongoing care and treatment. A separate release is not required between Northwest Laboratory and each patient of the Provider, as the requisite documents executed between the Provider and patient shall be sufficient.

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