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My Products

Rapid Antigen Test

$69.00

PCR Test

$139.00

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Total

$0.00

Insured Patients
Health Insurance Name*
Health Insurance Member Id*
Photo of Driver's License*
Photo Front Insurance Card*
Photo Back Insurance Card*
I hereby certify that the insurance information I am providing is active and accurate. I am giving consent for my COVID-19 testing to be submitted to my insurance. I am responsible for the partial/whole cost if my insurance only covers the partial cost of the test or in my insurance does not cover the cost of the test at all, or if the information I provided is inaccurate or invalid.
Signature

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Attestation for Uninsured Patients

The Health Resources & Services Administration(HRSA) reimburses healthcare offices for the costs of providing COVID-19testing for the uninsured. HRSA is afederal uninsured program that pays for COVID-19 services provided to anyonewithout health insurance. Everyone iseligible for COVID-19 services, no matter their immigration status.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Photo of Driver's License or Passport*
I verify that no other payer will reimburse for COVID-19 testing and that I currently do not have insurance.

By signing below, I verify that the above information is correct.
Signature

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Insured