WMCHealth COVID-19 Diagnostic Test Registration Form

PATIENT CONTACT DETAILS

First Name:

Middle Name:

Last Name:

Date of Birth (mm/dd/yyyy): 

Gender: 

Male           Female             Other

Address 1: 

Address 2: 

City: 

State: 

Zip Code (XXXXX): 

Email Address: 

Preferred Phone Number:                        (Best number we can reach you on)    

Phone Type:

Please select... Mobile Home Other

PATIENT DEMOGRAPHICS

Ethnicity:

Please select... Hispanic or Latino Not Hispanic or Latino Decline to Specify

Race:

Please select... American or Alaska Native Asian Black or African American Spanish American Indian White Other Race Decline to Specify

Have you been previously diagnosed with COVID-19?

Yes               No

INSURANCE INFORMATION

Are you Insured (Do you have insurance)?

Yes               No

Please be prepared to provide your Social Security number and/or Driver’s License ID when a WMCHealth representative contacts you to schedule your appointment over the phone.                                                                                                                                                                                           Comments:

                                                                           Insurance Carrier:

 (Ex: United Healthcare, Aetna, BlueCross Blue Shield etc.) 

Group Number: 

Member Number/ID:

Primary Insurer: 

Self          Spouse          Guardian

Comments: 

Please click link below to review WMCHealth Privacy Practices:  https://www.westchestermedicalcenter.org/Uploads/Public/Documents/WMC/NoticeOfPrivacyPractices.pdf

I have reviewed the WMCHealth Notice of Privacy Practices*