COVID-19 Screening Survey Holland

COVID-19 Test and Screening
Would you like to schedule a new appointment or change an existing appointment?*

Schedule a new appointmentChange an existing appointmentCancel an existing appointment
To make a change to your appointment time:
1. Scroll down to the Appointment Calendar.
2. Select a new appointment time slot.
3. Scroll to the bottom of the form and press submit.

To cancel your appointment:
1. Scroll down to the Appointment Calendar.
2. Deselect your current appointment time slot.
3. Scroll to the bottom of the form and press submit.
Location:*

91 Douglas Avenue Suite 110 Holland, MI 49424Special
Password: *
Please ask intake staff for password
Please note this testing location is open Monday, Wednesday, Thursday, & Friday (9:30am to 5:30pm), Tuesday (1pm-7pm), Saturday (9:30am to 5pm), and Sunday (9:30am-2:30pm).
This is a PCR Test. If you do not wish to receive this test, please fill out the form for the Rapid Antigen Test here.
Patient Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Email*
You will receive a link to access your results by email when they are ready. Please check your spam/junk folder as well.
Gender*

MF
Race*

Alaska NativeAmerican IndianAsianBlack or African AmericanNative Hawaiian or Pacific IslanderUnknownWhite or CaucasianOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown/Decline to AnswerOther
Mobile Phone Number*
Address (Current Address)*

Street Address

Street Address Line 2

CityState

Zip Code
How Did You Hear About NxGen's Covid Testing?

I clicked on an adI searched online for testingI saw a billboardSomeone told me about itOther
Covid-19 Test and Screening
Have you had close contact with a person who has been diagnosed with COVID-19?*

YesNo
Are you experiencing a cough?*

YesNo
Are you experiencing a fever?*

YesNo
Are you experiencing shortness of breath?*

YesNo
Are you experiencing fatigue?*

YesNo
Are you experiencing a sore throat?*

YesNo
Are you experiencing muscle pain or aches?*

YesNo
Are you experiencing headaches?*

YesNo
Are you experiencing diarrhea?*

YesNo
Are you experiencing loss of taste or smell?*

YesNo
Are you experiencing nausea or vomiting?*

YesNo
Do you have any of the following risk factors: cancer, chronic kidney disease, COPD, immunocompromised state from solid organ transplant, obesity, serious heart conditions, sickle cell disease, type 2 diabetes mellitus?*

YesNo
Are you pregnant?

YesNo
If you are experiencing symptoms of COVID-19, what was the date of symptom onset?

MonthDayYear
Leave blank if it does not apply
Is this your first COVID-19 Test?

YesNo
Payment Details
Because you are not experiencing symptoms, have not been recently exposed to anyone diagnosed with COVID-19, and do not have any risk factors, you are required to pay for your COVID-19 test.

Please note: Appointments not canceled within 24 hr of the appointment date and time will incur a $15 fee to cover administrative fees.
This is a PCR Test. If you do not wish to receive this test, please fill out the form for the Rapid Antigen Test here.

Insurance Information
Do you have a primary health insurance?*

YesNo
Please complete and attach a copy of your insurance card to this form.
Upload the front of your insurance card:

Cancelof
Upload the back of your insurance card:

Cancelof
Name of Insured: *

First NameLast Name
Date of Birth of the insured: *

MonthDayYear
Subscriber/Enrollee ID#: *
Group #:
Insurance Company:*
If you cannot find your insurance in the list, please enter it here:*
Patient Relationship to Insured:*

SelfSpouseChildOther
Please select which test you would like performed:*

COVID-19 Nasal Swab TestCOVID+ (COVID-19, Flu A and Flu B)COVID+ with RSVRespiratory Pathogen Panel
Collection Type

Nasal Mid-Turbinate
No food, fluids, smoking, or chewing gum 30 minutes prior to your test.

This test requires spitting into a collection tube so it may not be appropriate for young children

*** If you are planning to travel, saliva specimen tests are often not acceptable for travel. Check your travel destination's COVID-19 testing requirements. ***
While COVID-19 testing is covered under the CARES Act, testing for Influenza A and B are not. As a result, patients with insurance will have influenza testing billed to their insurance and will be responsible for any co-pays or coinsurance due from the testing.
A social security number, state of residence, and driver's license number/state identification number is needed to verify patient eligibility. If this information is not submitted, you will need to attest that you attempted to capture this information before submitting a claim and that the patient did not have this information at the time of service. Claims submitted without the necessary information may take longer to verify and will be billed to the client at $100 per test.
Social Security #:*
Would you like to provide your Driver's License or State ID?

Driver's LicenseState ID
Driver's License #:*
Upload your Driver's License (front):

Cancelof
Upload your Driver's License (back):

Cancelof
State ID #:*
Upload your State ID (front):

Cancelof
Upload your State ID (back):

Cancelof
Schedule Appointment*
Acknowledgment:

I authorize the laboratory to provide my health plan with the information on this form and other information provided by my health care provider if necessary for reimbursement. I understand that the laboratory may seek prior authorization for testing from my health plan on my behalf. I also authorize all benefits from the plan to be payable directly to the laboratory, and I agree to remit to the laboratory any payment for these services made directly to me. I understand that the laboratory may be an out-of-network provider for my health plan and that I am responsible for all amounts not reimbursed by my health plan. I hereby designate the laboratory as my Authorized Representative, as provided under ERISA, 29 C.F.R § 2560.5031 (b)(4), and/or as my Attorney in Fact, for the purpose of pursuing administrative appeals to which I am entitled and, if the laboratory deems it appropriate, any legal and/or equitable claims that I could bring against my health plan, and/or its administrators, with respect to their handling or resolution of my insurance claim.

I understand that in certain circumstances, the laboratory is required to report test data to relevant state public health agencies.

I agree that my de-identified specimen and test data (where information that could link me to the specimen or data has been removed, making it unlikely that I could be identified) may be retained, used and disclosed for research and/or to help develop products or services, in compliance with applicable laws.

I understand that I will not receive any royalties, payments, benefits or rights from any resulting products or discoveries, and that if I do not want my de-identified specimen and test data to be retained, used or disclosed for research or product development purposes I should call Customer Service at 1-855-776-9436.
Patient Signature: *

Clear
Please verify that you are human*
Date

MonthDayYear
Date
Insurance Code
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Credit Card Details
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Credit Card Number	Security Code
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COVID-19 Test and Screening

Patient Information

Covid-19 Test and Screening

Payment Details

Insurance Information