COVID-19 Screening Survey Holland

Would you like to schedule a new appointment or change an existing appointment? *

Schedule a new appointment Change an existing appointment Cancel 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: *

Ottawa County Department of Public Health 844 Washington Avenue Suite 4100 Holland MI 49423 Special

Password: *

Please ask intake staff for password

Please note this testing location is open Monday, Wednesday & Thursday (9:30am to 5:30pm), Tuesday (1pm-7pm), and Saturday (9:30am to 5pm).

Name *

First Name Middle Name Last Name

Date of Birth *

Email *

example@example.com

Gender *

M F

Race *

Alaska Native American Indian Asian Black or African American Native Hawaiian or Pacific Islander Unknown White or Caucasian Other

Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown/Decline to Answer Other

Mobile Phone Number *

Address (Primary Residence) *

Street Address

Street Address Line 2

City State

Zip Code

Have you had close contact with a person who has been diagnosed with COVID-19? *

Yes No

Are you experiencing a cough? *

Yes No

Are you experiencing a fever? *

Yes No

Are you experiencing shortness of breath? *

Yes No

Are you experiencing fatigue? *

Yes No

Are you experiencing a sore throat? *

Yes No

Are you experiencing muscle pain or aches? *

Yes No

Are you experiencing headaches? *

Yes No

Are you experiencing diarrhea? *

Yes No

Are you experiencing loss of taste or smell? *

Yes No

Are you experiencing nausea or vomiting? *

Yes No

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? *

Yes No

Are you pregnant?

Yes No

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

Leave blank if it does not apply

Is this your first COVID-19 Test?

Yes No

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.

Product Details

COVID-19 Nasal Swab Test

$ 100.00

Total

$ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Do you have a primary health insurance? *

Yes No

Please complete and attach a copy of your insurance card to this form.

Upload the front of your insurance card:

Upload the back of your insurance card:

Name of Insured: *

First Name Last Name

Date of Birth of the insured: *

Insurance ID#: *

Group #:

Insurance Company: *

If you cannot find your insurance in the list, please enter it here: *

Patient Relationship to Insured: *

Self Spouse Child Other

Please select which test you would like performed: *

COVID-19 Nasal Swab Test COVID+ (COVID-19, Flu A and Flu B)

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 License State ID

Driver's License #: *

Upload your Driver's License (front):

Upload your Driver's License (back):

State ID #: *

Upload your State ID (front):

Upload your State ID (back):

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

Insurance Code

COVID-19 Test and Screening

Patient Information

Covid-19 Test and Screening

Payment Details

Insurance Information