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Testing Insurance Form

    Administration Date

    Full Name

    Date of Birth





    Are you insured?
    Relation to insured?
    Primary Insurance
    Policy Number

    Are you experiencing any of the following symptoms? Sore throat, Cough, Fever, Shortness of breath, Diarrhea, Headache, Body aches, Nausea / Vomiting, Loss of Taste / Smell?

    Has anyone in your household, or any of acquaintances tested positive for COVID-19 within the last 14 days?

    Any recent travels outside of the State or Country?

    Photo of Insurance

    Take Photo of ID (Drivers License, Passport, State Issued ID)
    Type of Test

    I certify that the information provided on this form is accurate. I authorize the place of service to release the results of this test to the ordering provide. I further authorize the lab and the ordering provider to bill my insurance and to receive payment of benefits for the test ordered. I authorize the lab and the ordering provider to release to my insurance provider any medical information necessary to process this claim. I consent and give permission to the provider to contact me to discuss about the test results.

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