COVID Rapid Testing cash pay registration

COVID-19 Rapid Testing Registration Form

(For patients billing insurance)
In order to utilize your insurance for billing for the rapid COVID test, you will be required to attend a brief office visit with a provider and fill out a few more documents. These documents will be sent to you by our CMA after your registration is complete.
Patient Legal Last Name *
Patient Legal First Name *
Patient Name Used (If different)
Middle Initial (If applicable)
Legal Gender (on file with your insurance or what matches your ID) *
Date of Birth *

Month Day Year
SSN *
Full Address (Include Zip Code)
Cell Phone *
Work Phone
Email *
Contact Preferences ( Select All you are willing to receive)

Cell Phone Email Patient Portal Text
Parent/Guardian Name(s) (If applicable - please provide contact information if different than above)
Parent/Guardian Date of Birth

Month Day Year
Patient or Guardian Social Security Number (necessary for billing purposes - may give at the office or call us)
Parent/Guardian Address (If different than patient address)
Detailed Demographic Information

The following information is optional, however, it does help us apply for an obtain grants to better serve our community.
Primary Language
Race
Ethnicity *
Marital Status *
Sexual Orientation

Heterosexual Homosexual Pansexual Bisexual Other
Gender Identity

Transfemale (MtF) Transmale (FtM) Male Female Nonbinary Genderqueer Other
Assigned Sex at Birth

Male Female
Pronouns *

She/Her He/Him They/Them Other
Have you received the COIVD-19 vaccine?

YES NO
Are you currently experiencing difficulty with social determinants of health (safety, access to housing, food/water, utilities) and interested learning more about resources you may qualify for?

YES NO
Emergency Contact

We must legally have an emergency contact to reach out to in the case of risk of harm to you or others.
Emergency Contact Name
Relationship to Patient
Emergency Contact Phone Number
Insurance Information

We bill insurance as a courtesy. If you are self pay, all charges are due at time of visit unless arrangements are made ahead of time with the Clinic Director.
Please upload a photo of the BACK of your insurance card.
Cancel of
Please upload a photo of the BACK of your insurance card.
Cancel of
Primary Insurance Carrier
Policy Number
Who is the insured party?

Patient Guardian Guardian's spouse/significant other Other
What is the insured party's employer?
Insured Party's Date of Birth

Month Day Year
Insured Party's Address (If different than patient)
Insured Party's Email Address (if different than patient)
Insured Party's Phone Number (if different than patient)
Secondary Insurance Plan Carrier
Secondary Insurance Policy #
Who is the insured party for the secondary plan?

Patient Guardian Guardian's spouse/significant other Other
Insured Party's Date of Birth

Month Day Year
Insured Party's Address (If different than patient)
Insured Party's Email Address (if different than patient)
Insured Party's Phone Number (if different than patient)
Driver's License
Driver's License- Front Side

Cancel of
Driver's License- Back Side

Cancel of
Patient Driver's License Number
Issuing State/ Exp Date
Patient Preferences

Please indicate your preferences for the following (if you don't have a preference, you may leave blank).
My preferred pharmacy is *
My preferred emergency room is
My preferred imaging facility is
My preferred lab facility is
Signature

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COVID-19 Rapid Testing Registration Form

Detailed Demographic Information

Emergency Contact

Insurance Information

Driver's License

Patient Preferences