2022 Silver Lake Camp and Retreat Center Covid-19 PCR Test Registration (staff/volunteer)

My Products*

Silver Lake Camp and Retreat Center: 1 PCR TEST One test will be mailed to the shipping address provided below.

$29.99

Shipping and handling

$10.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Staff/Volunteer Information:
Camp Session Start Date:*
If your camp session start date is not listed above its because the order deadline has closed and we are no longer accepting orders for that start date.
Staff/Volunteer Information:

PLEASE MAKE SURE TO PROVIDE YOUR LEGAL NAME & CORRECT DATE OF BIRTH
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Race*
Ethnicity*
Parent / Guardian Information:

Please complete if under the age of 18
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
Parent/Guardian Phone Number
Please enter a valid phone number.

Shipping Address: location where you want your test kit to be delivered. Your test kit will ship the day after the order deadline closes and arrive the following week. The lab does not ship to PO Box addresses. NOTE: When shipping your sample back to the lab you must drop off at a FedEx Store. Do not schedule a pickup or use an unattended drop box. This will cause a shipping delay.*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Information:
Does you have insurance?*
By signing the box below, I am approving Heed Health to charge my credit card on file the lab processing fee for each UNINSURED PCR test. I understand the lab processing fee for each UNINSURED PCR test is $75 and will be charged before the test kit(s) are shipped.*

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Insurance as billing

Y
Who is your insurance provider?*
What is your insurance member ID number?*
Who is the policy holder?*
Policy holder's DOB*

MonthDayYear
Date
What is the camper's relation to the policy holder?*
Insured Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ICD10

Z20.822
COVID-19 Test

Y
Test

DNASCOV19
Send an AN kit to patient?

Y

Please click HERE to open and review the HIPAA & Consent Form. After reviewing, you will sign the box below. This will finalize your order.

Note: You do not need to print and sign the actual HIPAA form linked above, signing below is your attestation that you reviewed and agree to the document.
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have been provided a copy of Heed’s Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by Heed and how I may obtain access to and control this information.*

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Covid-19 PCR Test Registration