Covid-19 Registration Form

EPI-1

This form may be used to report suspected cases and cases of notifiable conditions in the US Virgin Islands (USVI), listed with their reporting time frames on the current USVI Notifiable Conditions List 2020. In addition, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means available. A Health Department epidemiologist will contact you if further investigation is required.
Patient Name (Last) *
Patient Name (First) *
Middle Initial
Parent/Guardian:
If patient is under the age of 18
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age *
Gender *

Female Male Other
Ethnicity *

Hispanic Not Hispanic
Race *

Black White Asian Other
Email *
example@example.com
Emergency Contact *
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact Relationship to Patient *
Please upload a current photo ID

I.E. Drivers Licence, Passport, etc.
Cancel of

There are two types of tests for Covid-19. Diagnostic tests, which can detect an active infection through either a molecular test or an antigen test, or Antibody tests that can detect previous infections.

If this test is for travel purposes and your destination requires a specific type of test please specify in the "other" section.
What type of testing would you like? *

Diagnostic Test Antibody Other
Are you currently presenting symptoms of Covid-19? *

Yes No

Insurance Information
Name of Primary Insurance Company: *
Policy ID#: *
Group No: *
Co Pay Amount:
Patient's Relationship to Policy Holder: *

Self Spouse Child Other
Policy Holder's Name: *
Policy Holder's Date of Birth: *

Month Day Year
Date
Secondary Insurance *

Yes No
Name of Secondary Insurance Company: *
Policy ID #: *
Group No: *
Please upload a copy of the FRONT and BACK of your health insurance card.

Cancel of

We only test Monday - Friday between the hours of 7am-7:30am at our Red Hook location.

Please note that we are unable to acomidate requests less than 24 hours in advance, if it is an emergency please call our office.

This is not a garentee of an appointment. Please wait for our office to contact you to confirm your appointment.
Date you would like to be tested

Month Day Year
Date
Alternate Date

Month Day Year
Date
Please list the names of the people in your party
If multiple people are being tested together, i.e. a family or crew

CONSENT FOR TREATMENT
I hereby consent to the performance of medical treatment and/or diagnostic procedures as deemed necessary oradvisable by my physician(s) at Red Hook Family Practice PC. I also understand I have the right to be informed about all treatments given to me and the right to decline any specific treatment should I choose. I hereby consent to the performance of all nursing and technical procedures and tests as directed by my physician's. Further, I understand that should any medical personnel, physician, or otherperson(s) be exposed, or report an exposure to, my blood or body fluids, my blood will be tested for blood borneinfections including Hepatitis Band C as well as HIV/AIDS. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examination at Red Hook Family Practice PC.
PATIENT HIPAA AWARENESS
With my permission, Red Hook Family Practice PC, which consists of Red Hook Family Practice, Yacht Haven Family Practice, and Cruz Bay Family Practice, may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Red Hook Family Practice PC Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have reviewed the Notice of Privacy Practices prior to signing this consent. Red Hook Family Practice PC reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, Red Hook Family Practice PC may call my home or other designated location that was provided on the registration form and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. If any contact information changes, it is my responsibility to complete a new registration form.

With my permission, the office of Red Hook Family Practice PC may mail to my home or other designated location that was provided on the registration form any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and or Confidential.

With my permission, the office of Red Hook Family Practice PC may e-mail to my email address that was provided during registration any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request in writing that Red Hook Family Practice PC restrict how it uses or discloses my PHI to carry out TPO.

By signing this, I am allowing Red Hook Family Practice PC to use and disclosure my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If any change in demographics or insurance information is made, it is my responsibility to inform Red Hook Family Practice PC and complete a new registration form.
By signing below, I agree that the information I have provided is true and accurate to the best of my knowledge.

By signing below, I understand and agree to the stated policies above.
Signature of patient or person acting on behalf of patient *

Clear
Date *

Month Day Year
Date
Should be Empty:

EPI-1

Insurance Information

CONSENT FOR TREATMENT

PATIENT HIPAA AWARENESS