COVID-19 Testing Registration Form

Are you currently on site, at Sayre Health Center's 59th & Locust St. location?*

Yes
No

Tell us about you.

First and Last Name*

First Last

Preferred Name*

Date of Birth*

Mailing Address

Address*

Street Address Address Line 2 City State ZIP Code

Contact Info:

Mobile Phone*

(Text Notifications will be sent to you here)

Email*

Gender & Sexual Orientation

Sex*

Male
Female
Unknown

Gender Identity*

Sexual Orientation*

Race, Ethnicity, Language Spoken.

Race*

Ethnicity*

Primary Language Spoken*

Language "Other"Selected Write in below*

Please write in the "other" language spoken.

Are You Homeless?*

Yes
No

Are You Disabled?*

Yes
No

Are You A Veteran ?*

Yes
No

Discharge Status*

Discharge Date*

Are You A Refugee?*

Yes
No

What Country Are You A Refugee From?*

Country

Are You a Migrant/Seasonal Worker?*

Do you Live in Public Housing?*

Y- Yes
N- No

Income Questions

What is Your Income?*

Income*

Insurance Questions:

"This service is FREE TO THE PATIENT. We will bill your medical insurance, however, if you have any co-pays, co-insurance, or deductible associate with your insurance those costs will be waived by Sayre Health Center. [Testing is not free. We are required to bill insurance or the CARES act for the uninsured.)

Do you Have Insurance?*

Yes
No

Insurance Company Name*

Put in N/A if you dont have insurance

Insurance Member ID Number*

Put N/A If you have no insurance

Consent to be registered*

I agree to Be Registered into the system

General Consent Statement:

I voluntarily request Medical services through this agency and request that an examination, laboratory tests, treatment and/or a suitable method of contraception, and counseling be provided to me. I understand that I will have the opportunity to have all my questions answered, and that my signature applies to the Eligibility information and General Consent statement for services on the date electronically signed.

Acknowledgement of Receipt of Notice of Privacy Practices: This form is used to obtain acknowledgement of your receipt of our notices of privacy practices, or to documnent our good faith effort to obtain that acknowledgement. I have read the Notice of Privacy Practices and understand my rights contained in the notice. Byway of my signature, I give Sayre Health Center my authorization and consent to use and disclose my protected healthcare information for the purposes of treatment, payment, and healthcare operations as described in the notice of privacy practices.

Release of Insurance Information and Assignment of Benefits: I request that payment of authorized Medicare, Medicaid, HMO, or Commercial Insurance or public benefits be made on my behalf, to Sayre Health information about me to release to the Centers for Medicare and Medicaid Services or Commercial Company and its agents any information needed to determine these benefits or the benefits payable for related services

Download Privacy Statement here: https://www.communitycovidtest.com/wp-content/uploads/2021/01/NOTICE-OF-PRIVACY-PRACTICE.pdf

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