St. Joseph Hill Academy Super Health Pharmacy COVID-19 Testing Form

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Image Field
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Select type of COVID-19 Test* This field is required.
Covid-19 RT-PCR Nasal Swab Test via Lab (FREE-Results within 1-2 days)
Rapid Covid-19 Antigen Nasal Swab Test (Results within 15 minutes) $65 (Free with most Medicaid & Medicare Part B Plans)
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Appointment For COVID-19 Test
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Appointment (Result by 1-2 business days)
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Pharmacy PhoneFor your reference
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Patient Name* This field is required.
First Name
Last Name
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Middle Initial
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Date of Birth* This field is required.MM/DD/YYYY
Please make sure your birthday is in this format (MM/DD/YYYY) otherwise your registration might be rejected (ex. 12/01/99)
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Patient Address * This field is required.
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City* This field is required.
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State* This field is required.
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ZIP Code* This field is required.
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Race** This field is required.Required By CDC
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Ethnicity** This field is required.Required By CDC
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Cell Phone* This field is required.
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Insured's Name
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Relationship to Patient
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Gender* This field is required.
MaleFemale
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Are you Pregnant/Postpartum?
YESNO
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Primary InsuranceName of Insurance Company
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Group #
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ID#
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COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
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ICD-10 Code* This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.59 Asymptomatic, no known exposure, results unknown or negative
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Email *Very important your email is accurate for testing instructions.
example@example.com
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Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Secure Payment Portal* This field is required.Payment is nonrefundable; We will provide an itemized receipt if you would like to submit this to your insurance for possible reimbursement. SELECT YOUR OPTION FROM THE DROP DOWN
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ORDER SUMMARY
Total costUSD
Rapid COVID-19 TESTFastest way to get in and out is by paying online
$120.00Edit
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Rapid Antigen Test
Rapid Antigen Test
Medicaid-Free
Medicare Part B-Free
Rapid COVID-19 Test
Total cost $0.00
Credit Card-Paying Online is the fastest method!
First Name
Last Name
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Would you like to do the Free Test through the Lab as well with your Rapid Test?* This field is required.Results within 2-3 days
YESNO
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You will now be redirected to siParadigm Lab Portal. You must register with the lab in order to get the Free PCR Test. Results will take 1-2 days. You may need to use different email addresses for different patients. Please provide the confirmation number you get from the lab via email when you arrive at the Clinic.
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