ICC East Peoria COVID-19 Testing Registration

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If you would like to become a frequent tester and not have to signup every single week, then please click here: https://form.jotform.com/220246477976164
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Choose the type of test you wish to register for. Only one test allowed per day (per insurance requirements).* This field is required.To cancel an appointment, call 309-962-3123
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.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
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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?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 cardWe cannot process your COVID test if you do not provide pictures of your insurance card
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Upload back of cardWe 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 and New Years 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 - 1pm. (Last Test is at 12:30pm) New Years Eve: 8:30am - 3pm. (Last Test is at 2:30pm)
Christmas Eve
New Years 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.
Huge
Large
Normal
Small
Ok
Ok
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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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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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