Patient Insurance Registration Form
Testing Location
West Hartford, CT ( 1001 Farmington Ave )
Oxford, CT ( 100 Oxford Rd )
Trumbull, CT ( 115 Technology Dr 203A )
Manhattan East, NY ( 115 East 57th St Suite 1450 )
Manhattan West, NY ( 324 West 47th St )
Eastchester, NY ( 271 Main St )
White Plains, NY ( 115 Westchester Ave )
Downtown soho, NY (137 Thompson st)
Name
*
First Name
Last Name
Sex
*
M/F
Date Of Birth:
*
Format MM/DD/YYYY
Home Address or Insurance Registration Address
*
*Where medical insurance sends the bills
City
*
State
*
XX format
Zip Code
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of Primary Insurance
*
Relationship to Insured
*
Self
Spouse
Children
Other
Insured Date of Birth
*
Format MM/DD/YYYY
Group ID Number
*
Insurance ID Number
*
Primary Insurance Billing Address (from back of the card)
*
Insurance Phone Number (from the back of the card)
*
2nd Insurance Company Name (for those that apply, Medicare supplemental insurance etc. )
Group ID Number
Insurance Id Number
Signature
Clear
Submit
Should be Empty: