If you have medical insurance, it fully covers the cost with no co-pay as long as you are getting the test done for medical necessity. You may receive a statement from your insurance company - an explanation of Benefits (EOB) - but it is not a bill and there is nothing to pay even if a balance is indicated.

If you don.t have insurance, or test for the purpose of Travel, back to school and/ or back to work, you will need to pay for test out of pocket. Payment for the test is expected at the time of sample collection.

Please note that all participants are required to arrive at the designated test location and wearing a mask.

Please register your test kit using the sample barcode and your information.

Location*

Date of Appointment*

Time of Appointment*

Sample Barcode*

First Name*

Last Name*

Date of Birth*

Gender*

Male

Female

Race*

Ethnicity*

Address*

City*

State*

Zip Code*

Mobile Phone* Format: 5553334444

Email*

Photo of ID

SSN

Passport Number

Photo of prescription

I don't have insurance (If you HAVE insurance and don't provide it, you will be BILLED!)

Primary Insurance*

Insurance ID#*

Group # (Optional)

Picture of Insurance Card (front)

Picture of Insurance Card (back)

Primary Physician Name (Optional)

Physician Phone (Optional) Format: 5553334444

Reason for obtaining a COVID/FLU test today?

Experiencing signs/symptoms associated with COVID-19

Cough

Shortness of breath

Fever, unspecified

Suspected exposure to COVID-19

Acknowledgement and Authorization to Test:

You must acknowledge and authorize in order to submit this form.

Collection Date*

Time of collection*