Marine Medical PERSONAL INFORMATION * * *DOB: *GENDER: MALEFEMALE * * Patient Service Center Order VESSEL INFORMATION PORT NAMEIMTT Bayonne, 250 E 22nd St, Bayonne, NJ 07002Buckeye – Port Reading, State Street, Port Reading, NJ 07077Buckeye – Perth Amboy, 1200 State Street, Perth Amboy, NJ 08861Gordon Terminal, 2 New Hook Rd, Bayonne, NJ 07002Kinder Morgan – Carteret, 78 Lafayette Street, Carteret, NJ 07008Kinder Morgan – Perth Amboy, State Street, Perth Amboy, NJ 08862New York Container Terminal, 300 Western Ave., Staten Island, NY 10303Nustar – Linden, 3700 S Wood Ave, Linden, NJ 07036Phillips 66 – Bayway, 1400 Park Avenue, Linden, NJ 07036Red Hook Container Terminal, 70 Hamilton Ave, Brooklyn, NY 11231Shell – Sewaren (formerly Motiva), 115 State Street, Sewaren, NJ 07077PBF Energy – Paulsboro, 800 Billingsport Rd, Paulsboro, NJ 08066 TEST C455 COVID-19, PCR *By clicking this box, I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering provider/facility, however such results shall be used solely for clinical diagnostics/treatment purposes and shall not be used for any forensic purposes related to my employment or other legal or administrative purposes. The specimen identified by this form is my own, is fresh and unaltered. I authorize Accu Reference to bill my insurance directly for services I receive and acknowledge that Accu Reference may be an out of network provider with my insurance. I am aware that in some instances my provider may send payment directly to me, in such instances I agree to endorse the check and forward it to Accu Reference Medical Lab within 30 days.
