Montclair Town Testing

Welcome to The MediStation

Patient Information Verification. Please note that all forms completed through this form are encrypted and fully HIPPA compliant.
Patient Name *

First Name Last Name

Insurance Card (Front)

Please take a photo of your insurance card. Allow access to the camera and when the image is in focus press take. If you do not have insurance, please ask our staff for a Non-insurance form. Complete the form and take a photo of the completed non-insurance form.
Take Photo *

Name of Insurance Company *
(If you DO NOT have insurance please write Cares Act)

Insurance Policy Number (Numbers & Letters) *
(If you DO NOT have insurance please write Cares Act)

Driver's License or Photo ID for Patient or Legal Guardian.

Please take a photo of your Driver's License or photo ID. Please allow access to the camera, when the image is in focus press take photo.
Take Photo *

Have you travelled internationally within the last 14 days? *

Yes No
Have you had any symptoms consistent with the Covid-19 virus? *

Yes No
Have you been around people without masks at work, school, gym or any other public place? *

Yes
Have you had possible exposure to someone with suspected Covid-19? *

Yes

I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment to myself/child/ward. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services. I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means; Voice, text and email. If a check is sent directly to you from the insurance company for this testing, you agree to sign it and send the check directly to The MediStation LLC.

Welcome to The MediStation