9635 Hillcroft St.                                                           
Houston, Texas - 77096
 
RESULTS IN 6 - 12 HOURS
WALK-INS WELCOME !!
 
Phone: (713) 242-8653
Email: info@rapiddxlabs.com
UPDATE:The HRSA COVID-19 Uninsured Program (UIP) will soon stop accepting claims due to a lack of sufficient funds. The program will continue to accept claims for testing until 11:59 PM on March 22, 2022.(Please visit the link for more details) COVID-19 Uninsured Program Claims Submission Deadline FAQs.

Beginning MONDAY, April 10th, Rapid Dx will only provide testing to those that are insured OR self-paying. If a patient is uninsured but willing to pay out of pocket, the cost of a COVID-19 test will be $102.98 and a Respitory Pathogen Panel (RPP) will be $250.00.
Nurses Signature:

Patient Registration

Details must match your Government ID or Passport/ Los detalles deben coincidir con su identificación governamental o pasaporte

Billing Information

Please fill out the fields below to provide your consent to authorize the lab (Rapid Dx), and those assisting with your test to bill your insurance for the service provided. /Complete los campos a continuación para brindar su consentimiento para autorizar al laboratorio (Rapid Dx) y a quienes lo ayudan con su prueba a facturar a su seguro por el servicio brindado.
Medicare -- Medical (Part B) Coverage/Medicare -- Covertura medica (Parte B) *
Private Insurance Coverage/Aseguranza Privada *
*** Note: VA Insurance is not accepted. If you have secondary insurance, please provide that as your primary insurance. Otherwise, you will have to self-pay. 
 *

Do you have secondary insurance? *
By signing this document, I attest that the above mentioned financial information is true and accurate to the best of my knowledge. Rapid Dx Labs may contact me should they experience issues with the indicated payment options or other concerns./Al firmar este documento, acepto la responsabilidad financiera y estoy al tanto de las tarifas de las pruebas. Entiendo que soy responsable de presentar mi propio reclamo de seguro. Como paciente de Medicare, también soy consciente de que soy responsable del pago a Rapid DX LLC. Si Medicare niega el pago. *
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Patient COVID-19 Screening Questionnaire

Representations

First COVID Test? Es su Primer Examen de COVID-19? *
Are you employed in Healthcare?/Esta empleado en un centro de salud? *
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) /¿Está experimentando actualmente, o ha experimentado en los últimos 14 días, alguno de los siguientes síntomas? (Tómese la temperatura antes de responder esta pregunta). *
 YesNo
Fever/ Fiebre
Cough/ Tos
Shortness of breath or difficulty breathing/ Falta de aire o difficultad para respirar
New loss of taste or smell/ Nueva perdida del gusto o olfato
Chills/ Escalofrios
Head or muscle aches/ Dolor de Cabeza o Musculos
Nausea, diarrhea, vomiting (vomito)
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?/En los ultimos 14 dias, ha estado en proximidad con alguien que experimento algun simptoma mencionado o esta experimentando algun simptoma mencionado ahora? *
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?/En los ultimos 14 dias, ha estado cerca de alguien que fue positivo de COVID-19? *
Hospitalized in the last 14 days?Ha sido hospitalizado en los ultimos 14 dias? *
Resident in a congregate care setting (including nursing homes, residential care for intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting)?/Es residente de alguna situacion de vivir en grupo (como asilo de ancianos, centro de atencion residencial para desabilitaciones intellectuales o de desarollo, centro psiquiatrico, casa de grupo, pensiones y casas de acogida, refugio para indigentes, orfanato, o otro lugar?) *
Pregnant?/Embarazada? *
Traveled in the last 14 days?/Ha viajado en los ultimos 14 dias? *

Completion

I hereby certify that the responses provided are true and accurate to the best of my knowledge./Certifico que la información que he proporcionado anteriormente es exacta a mi leal saber y entender. *
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