227 S 59th Street,Philadelphia, PA 19139 COVID-19 Testing Registration FormAre 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*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mailing AddressAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Info:Mobile Phone* (Text Notifications will be sent to you here)Email* Gender & Sexual OrientationSex* Male Female Unknown Gender Identity*UnknownMaleFemaleFTM Transgender Male/FemaleMTF- Transgender Female/MalG- Gender Queeer: Neither Exclusively Male no FemaleO- OtherD- DeclinedSexual Orientation*S- StraightG- GayL- LesbianB- BisexualO-OtherRace, Ethnicity, Language Spoken.Race*C- WhiteB- Black or African AmericanA- AsianJ- Native HawaiianP- Other Pacific IslanderMore than 1Ethnicity*L- Latino/HispanicX- Not Hispanic or LatinoO- OtherN- RefusedPrimary Language Spoken*EnglishSpanishOtherLanguage "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*YesNoR- REfusedDischarge Date* MM slash DD slash YYYY Are You A Refugee?* Yes No What Country Are You A Refugee From?* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are You a Migrant/Seasonal Worker?*M- MigrantS- SeasonalN- Not Migrant/SeasonalR-RefusedDo you Live in Public Housing?* Y- Yes N- No Income QuestionsWhat is Your Income?*Income* Weekly Bi- Weekly Semi Monthly Monthly Annually 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 insuranceInsurance Member ID Number* Put N/A If you have no insuranceConsent to be registered* I agree to Be Registered into the systemGeneral 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.pdfCommentsThis field is for validation purposes and should be left unchanged.