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
Ad
dress 1:
Ad
dress 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
*