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  • Test Referral 2

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    Chango15
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    This document is a COVID-19 PCR test referral for Juan Fuentes Fuentes, with his personal information and travel declaration form number listed. The referral is signed by Dr. Carlos R. Mellado López and states that the test type is a PCR-Molecular test with a diagnosis code of Z20.822. The referral notes that it is issued under the emergency powers of the Puerto Rico Department of Health and government, and that neither the government nor health department are responsible for any harm caused by the referral or COVID-19 test.

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    This document is a COVID-19 PCR test referral for Juan Fuentes Fuentes, with his personal information and travel declaration form number listed. The referral is signed by Dr. Carlos R. Mellado López and states that the test type is a PCR-Molecular test with a diagnosis code of Z20.822. The referral notes that it is issued under the emergency powers of the Puerto Rico Department of Health and government, and that neither the government nor health department are responsible for any harm caused by the referral or COVID-19 test.

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    © All Rights Reserved
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    2 views1 page

    Test Referral 2

    Uploaded by

    Chango15
    This document is a COVID-19 PCR test referral for Juan Fuentes Fuentes, with his personal information and travel declaration form number listed. The referral is signed by Dr. Carlos R. Mellado López and states that the test type is a PCR-Molecular test with a diagnosis code of Z20.822. The referral notes that it is issued under the emergency powers of the Puerto Rico Department of Health and government, and that neither the government nor health department are responsible for any harm caused by the referral or COVID-19 test.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    COVID-19 PCR TEST REFERRAL FOR TRAVELERS

    PUERTO RICO DEPARTMENT OF HEALTH

    Name and Last Name: Juan Fuentes Fuentes 

    Date of Birth: 30/09/1956 


      (dd/mm/yyyy)

    ID Type: Passport 

    ID Number: 573550970 

    Travel Declaration Form Number: 210510182513UKSGN 

    Traveler’s Category QR (only for the Department of Health)

    Test Type: PCR-Molecular


    Diagnosis: Z20.822

    Carlos R. Mellado López, MD


    Lic. No.: 14376
    NPI: 1104847268

    This referral is issued under the powers conferred to the Secretary of Health in accordance with Law 81 of March 14, 1912, 3
    L.P.R.A. sec. 171 et. seq., and it is generated under the protection of the state of emergency decreed by the Government of
    Puerto Rico under Article 6.10 of Act No. 20-2017, 25 L.P.R.A. sec. 3650, and the immunity granted to health professionals in
    this state of emergency under the Claims and Lawsuits Against the State Act, 32 L.P.R.A. sec. 3077 et seq., And Executive Order
    2020-36.

    In accordance with these legal precepts, neither the Government of Puerto Rico, the Department of Health, nor its Secretary,
    are responsible for any damage or harm that this referral may cause and / or any test performed to detect COVID-19.

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