Brixmor Houston Covid-19 Rapid Testing Cares Act Patient Registration

Covid-19 Rapid Testing Cares Act Patient Registration
No wait, results in 15 minutes
PLEASE NOTE THAT THIS IS ONLY FOR PATIENTS WITHOUT HEALTH INSURANCE

If you do not have health insurance, we can offer you a no cost free rapid Covid-19 test.
Select Location
Billing TIN
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ID Type
ID Number
Patient Gender
Patient Account Number
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
Service Type
Date of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Admission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Discharge

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Patient Email
example@example.com
Provide Photo of ID
With my signature below, I confirm that all information provided in this form is true and accurate. I understand that if I provide false or inacurrate information, then it is considered FRAUD, with the potential to be punished by the fullest extent of the law.
Signature
Should be Empty:

Covid-19 Rapid Testing Cares Act Patient Registration