Premier COVID Testing

Premier COVID Testing
Patient Registration and Screening
Patient Details
Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Race (Check all that apply)
Other
Ethnicity
Photo ID
Please upload a photo of your Driver's License, State ID or Passport
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Photo ID Number
Number on the photo identification submitted
Patient Contact Information
Address
Email

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Health Screening
Are you experiencing any of the following symptoms?
Other
Have you had contact with anyone who has COVID-19 or COVID-like symptoms within the past 14 days?
Do you have health insurance?
I attest that at the time of sample collection I do not have medical insurance, and authorize the release of my personal information to the Health Resources and Services Administration, (HRSA) so they will reimburse the cost of testing my sample.
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Health Insurance Information
Health Insurance Provider
Identification Number
from your insurance card
Group Number
also from your insurance card
Insurance Card
Please submit a photo of your insurance card.
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The cost of providing COVID-19 testing at our facilities is fully covered by all insurance providers with no out of pocket cost to our patients. Participants must provide a copy of their medical insurance at the time of sample collection in order to receive a COVID-19 test.

Disclaimer
I, the undersigned, have read and agree to the terms and conditions associated with receiving rapid and PCR COVID-19 testing results at no cost to me, and I am voluntarily supplying my sample for testing.
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