Pre-Op COVID Testing Request Form

As part of pre-op testing, COVID testing must be completed for all patients. Tests must be scheduled 5 days prior to the procedure date (please note: date of procedure is day 0). Practices request the test by completing this online form. Upon completion of the form, the call center will email the practice’s point of contact (point of contact will be indicated on the form) to confirm and provide scheduling information. It is the responsibility of the practice to communicate the appointment confirmation and instructions with the patient.

Before completing the form, please indicate:

Is the provider who is performing the procedure an APS (Advanced Physician Services) or BSMG (Bon Secours Medical Group) provider?

YesNo

Where is the procedure being performed?

Please Note:

This form is for patients whose procedures are either conducted by an Advanced Physician Services (APS) or Bon Secours Medical Group (BSMG) provider or for a procedure conducted at a WMCHealth facility.

All other test requests can be directed to the WMCHealth COVID-19 community telephone request line at 914-909-6754 or you can request a diagnostic/swab test appointment by filling out the appointment request form by clicking the following link; https://wmchealthnetwork.tfaforms.net/256

Please advise the patient that they will be contacted by a WMCHealth representative within 72 hours to schedule their appointment.

Patient Details

Patient's Last Name

Patient's First Name

Patient's Date of Birth ( mm/dd/yyyy)

Patient's Phone Number (xxx-xxx-xxxx)

Phone Type

Patient's email

Patient's Address Line 1

Patient's Address Line 2

City

State

Zip Code

Practice Details

Practice Point of Contact

Practice Point of Contact e-mail

Practice Point of Contact telephone number (xxx-xxx-xxxx)*

COVID and Procedure Details

Date of Procedure

COVID Test Location (All sites are closed on weekends. Additionally, Valhalla is closed on Wednesdays.)

IMPORTANT: Is this procedure a late add-on? Please call 914-458-3648 for assistance. (please call if you need your patient to go through the tent emergently.

Is this procedure a late add-on?

YesNo

STOP!!! PLEASE CALL 914-458-3648 FOR ASSISTANCE

COVID Test Date
Reference image below when selecting test date.

Please Do Not provide the patient with an appointment time until you have received an email confirmation.
Appointment Time - Valhalla (Not Available Saturdays or Sundays)

Please Do Not provide the patient with an appointment time until you have received an email confirmation.
Appointment Time - Mid-Hudson (Not Available Saturdays or Sundays. Only AM appointments Mon-Fri.)

Please Do Not provide the patient with an appointment time until you have received an email confirmation.
Appointment Time - Health Alliance (Not Available Saturdays or Sundays)

INSURANCE INFORMATION

Appointments will not be scheduled without insurance information. Insurance Carrier:

Group Number:

Member Number/ID:

Primary Insurer:

Patient Spouse Guardian

Comments:

Name of the provider performing the procedure

Procedure approved by (Name of Department Director or designee):

Comments:

Forms

Do you have any related forms to attach for this request?

YesNo

Upload your completed consent form:

Contact Information