COVID-19 Test Registration

Fields marked with * are required.

Facility Name

Is this your first COVID-19 test?
Yes No

Are you exhibiting COVID-19 symptoms?
Yes No

First Name

Middle Name

Last Name

Date of Birth (MM-DD-YYYY, Enter just the numbers w/o the hyphens (dashes))

Gender

Email Address (No Copy & Paste allowed. If your email is incorrect, you will not receive your test report.)

Confirm Email Address (No Copy & Paste allowed)

Cell Phone No.
(10 digits only, no hyphens)

Other Phone No.
(10 digits only, no hyphens)

Street Address

City

State

ZipCode

Country

Your Race

Your Ethnicity

What tests are you requesting?
PCR
Rapid Antigen
Rapid Antibody

Note: Take pics from close to fill the screen. Allow time for camera to focus. Hold camera steady while clicking. Preview the image. Retake, if you can't read.

Photo ID(e.g. Passport picture page, driver's license, etc. Change your camera/photo settings to files of max file size of 6MB and image types of JPG, PNG, or PDF.)

Browse

How do you want to pay? Insurance Credit Card on Site Cash on Site No Insurance

Insurance Card Front (Change your camera/photo settings to files of max file size of 6MB and image types of JPG, PNG, or PDF.)

Browse

Insurance Company Name

Insured's Group ID

Insured's Policy ID

Create Password to View Report (6 to 8 alphabets and numbers, no special symbols. Link to view will be sent via email. Take a picture for future use once the passwords match.)

Confirm Password to View Report (6 to 8 alphabets and numbers, no special symbols. Link to view will be sent via email. Take a picture for future use once the passwords match.)

Patient Privacy Notice, Acknowledgement and Billing Authorization

HIPAA: We are required by law to provide you this notice about how we plan to use and share your health information. Based on your request for testing, we plan to use and share your health information provided in compliance with the HIPAA guidelines. It is your right to have your personal health information to be used for purposes only for which it is intended and to be shared to fulfill your request accordingly. The Privacy Rule allows provider to use and disclose protected health information. Your permission (authorization) is necessary before your health records are shared for any other reason.

BILLING: The cost of the COVOID-19 test will be billed directly to your health plan if you are insured, or if you are uninsured, the cost will be billed to the appropriate government program. The cost of the test is based on rates established by the Centers for Medicare & Medicaid Services (CMS).

UNINSURED PATIENTS STATEMENT: I do not have health insurance coverage of any kind through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program as of today's date.

I declare under penalty of perjury that the above information I have provided is true and accurate.