Bloomington COVID-19 Testing Registration

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Please go to this form: https://form.jotform.com/223555072556155 to register for a test.
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This form is no longer active. Please see previous slide for the new form.* This field is required.
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Choose the type of test you wish to register for: PCR/nasal swab or antibody test . Only one test allowed per day (per insurance requirements).* This field is required.To cancel an appointment, call 309-962-3123
Nasal Swab for Airline - PCR/NAAT (PCR tests cannot be performed after 3pm)
Antibody Test (IGM, IGG)
Rapid Nasal Swab
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Full Name - NOTE: if you are registering for the Nasal Swab PCR test for airline travel, you MUST enter your name exactly how it appears on your passport or/and driver's license* This field is required.
First Name
Last Name
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Parent/Guardian First and Last Name (For Minors Only)
First Name
Last Name
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Gender
Male
Female
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Ethnicity
Hispanic
Not Hispanic
Prefer not to answer
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Race
American Indian or Alaska Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
White
Other race or multiracial
Prefer not to answer
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Date of Birth* This field is required.MM/DD/YYYY
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E-mail* This field is required.
example@example.com
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Phone Number* This field is required.NO INTERNATIONAL NUMBERS Example Area Code XXX Phone Number XXX-XXXX
Area Code
Phone Number
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Address* This field is required.Address
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Type of Insurance (If Applicable)* This field is required.If you have insurance, we cannot process your COVID test if you do not provide your insurance information. The United States Department of Health and Human Services is no longer paying for the testing, treating and vaccinating of uninsured patients. All patients must provide health insurance information or self-pay
I have Medicaid/Medicare, or other government health insurance coverage
I have Commercial Insurance
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Social Security Number* This field is required.
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I understand CampusTown Urgent Care will submit a bill to my insurance company, Medicare, Medicaid, as applicable. I understand if I am uninsured, a bill will be submitted to the federal government pursuant to the Families First Coronavirus Response Act, Public Law 116-127, March 18, 2020.* This field is required.
Yes
No
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How would you like to enter you insurance information?* This field is required.We cannot process your COVID test if you do not provide your insurance information
Take pictures of card
Enter insurance information as text
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Enter your insurance card information exactly how it appears on your insurance card. We cannot process your test if your insurance information is not accurate.

Policy Holder Name    Policy Holder Name *
Member ID or Subscriber ID       Member/Subscriber ID *
Group Number    Group Number *
Policy Holder's Birth Date    Policy Holder's Birth Date *
Claims Mailing Address    Claims Mailing Address *
Insurance Carrier      Insurance Carrier *
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Upload front of card* This field is required.We cannot process your COVID test if you do not provide pictures of your insurance card
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Upload back of card* This field is required.We cannot process your COVID test if you do not provide pictures of your insurance card
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How would you like to enter you insurance information?* This field is required.We cannot process your COVID test if you do not provide you insurance information
Take pictures of card
Enter insurance information as text
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Enter your insurance card information exactly how it appears on your insurance card. We cannot process your test if your insurance information is not accurate.

Policy Holder Name    Policy Holder Name *
Member ID or Subscriber ID       Member/Subscriber ID *
Group Number    Group Number *
Policy Holder's Birth Date    Policy Holder's Birth Date *
Claims Mailing Address    Claims Mailing Address *
Insurance Carrier      Insurance Carrier *
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Policy Holders Date of Birth* This field is required.
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Upload front of Insurance Card* This field is required.We cannot process your COVID test if you do not provide pictures of your insurance card
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Upload back of Insurance Card* This field is required.We cannot process your COVID test if you do not provide pictures of your insurance card
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Are you experiencing any of the following* This field is required.
I am experiencing symptoms such confirmed fever, subjective fever (e.g. feel warm), cough, shortness of breath, muscle aches, nausea, vomiting, diarrhea, abdominal pain, headache, scratchy throat, runny nose, decreased smell or taste, or generalized fatigue.
I may have been exposed to COVID-19 by a confirmed patient or PUI (Patient Under Investigation)
I am not currently experiencing symptoms. I would like to have the diagnostic test for Coronavirus to determine whether I might be an asymptomatic or pre-symptomatic carrier.
I am experiencing symptoms not listed above.
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Please describe your symptoms.
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1.) I provide voluntary consent for myself and all listed parties to receive medical evaluation and diagnostic testing. 2.) I understand that if I have commercial insurance or any type of governmental coverage or other third-party coverage (Medicare, Medicaid, VA., etc.), the facility will bill that specific insurance coverage. I further understand that under current Federal Legislation, most insurance companies are covering testing in full without assessing patient copays or deductibles. However, there are certain limitations and restrictions, and this enhanced coverage is subject to change at any time. I agree to be responsible for any balances not covered by my insurance. If I am uninsured, I understand the facility will bill the government pursuant to the Families First Coronavirus Response Act. PUBLIC LAW 116-127- MAR. 18, 2020*. 3.) I hereby assign to the Clinic any claim or other right I have to reimbursement. I authorize payment to be made directly to the Clinic and authorize the Clinic to bring legal action in its own name to collect any reimbursement owed to me. 4.) I have reviewed to my satisfaction the Clinic's "Notice of Privacy Practices".* This field is required.Signature of Consent
Clear
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Terms of Service* This field is required.
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Unrequire
Yes
No
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On Christmas Eve, our hours will be different than normal. Please select the day you would like to sign up for a test. (Select "Other" if you would like to sign up for a normal appointment not on those days)* This field is required.Christmas Eve: 8:30am - 12pm.
Christmas Eve
Other
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Sorry, PCR testing will not be available on that day. If you would like to get tested, please register for another day.* This field is required.
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Appointment time* This field is required.Nasal swab-Airline tests must be scheduled before 3:00 pm
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Christmas Eve Appointment* This field is required.
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New Years Eve Appointment* This field is required.
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covid19-bloomington@illinoisastc.com
covid19-bloomington@illinoisastc.com
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Confirmation:
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If you wish to cancel an appointment, call 309-962-3123

IF YOU DO NOT RECEIVE A CONFIRMATION NUMBER OR EMAIL, YOU MUST TRY REGISTERING AGAIN FOR A DIFFERENT TIME SLOT.

IF YOU DO NOT HAVE A CONFIRMATION NUMBER UPON ARRIVAL, WE WILL NOT TEST.
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