Health Insurance COVID-19 Positive Declaration Form
Please complete this form to declare your COVID-19 positive status to your health insurance provider.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Positive COVID-19 Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How was your positive COVID-19 test confirmed?
*
PCR Test
Antigen Test
Other
Please list your current symptoms (if any)
Are you currently hospitalized due to COVID-19?
*
Yes
No
Additional comments (optional)
Submit Declaration
Should be Empty: