MyTexas Covid-19 Houston Consent To Testing

Welcome to

MyTexas Covid-19 Houston (MTCH)

Health Questionnaire & Consent to Covid-19 Testing

Form Homepage - Please complete all questions accurately to the best of your ability
Have you (or person getting tested) tested with MyTexas Covid-19 Houston before? *

Yes, I have tested with MTCH before No, this will be my first time testing I tried pulling up my information but it was not found!
Where will you be testing? *

MyTexas Covid-19 Houston

So, You've Been Here Before? GREAT, Welcome Back!

You have selected:

- Yes, I have been tested with MyTexas Covid-19 Houston before

If this is in error, please use the back button and select another option on the homepage.

If you have questions, find a MyTexas Covid-19 Houston (MTCH) Team Member and we will be happy to help.

- PAGE 2 -
Returning Patient Verification

Please completely answer all questions
We need your help to verify your identify:
- Frist Name
- Last Name
- Date of Birth
The information you enter needs to match what you input before.

ENSURE THERE ARE NO SPACES AFTER YOUR NAME(s)
Patient First Name (name of the person who is being tested) - case sensitive *
First Name (Given Name)
Patient Middle Name
Patient Last Name (name of the person who is being tested) - case sensitive *
Last Name (Family Name)
Birth Date (of the person being tested) *

Month Day Year
Date
Have you entered the information as it appears on a form of ID? *

Not Ready (default) Yes, I have entered the information correctly, please find me in the system
Let's find you in the system...
you will need to present a photo ID that matches this information to be tested
*
No Match Found - Go Back to Start (home) Page or Select "Not Ready" above and renter information
Number *
ID On File? *
Would you like to add ID information at this time?

Yes - I can take a picture of my (or Parent/Guardian's) ID (front only) No - I do not have picture ID
Picture Identification: Driver License (Front) |State ID | Passport

Cancel of
Insurance On File? *
Issue With Insurance? *
Notes on Insurance Issue
Would you like to add or Update Insurance information at this time?

Yes - I can take a picture of my card (front & back) Yes - but I do not have my insurance card with me No - I do not have insurance/ No Updates to my Insurance Situation
Existing Patient Insurance Card (Front)

Cancel of
Existing Patient Insurance Card (Back)

Cancel of
Returns Address
Returns Gender
Returns Cell Phone Number
Please enter a valid phone number.
Returns Contact Email
example@example.com (if no email, put no@email.com - note this limits results communication to cell phone only)
Returns Social Security Number
Return Insurance Provider
Return Insurance Number
Return_diag_1
Return_ins_group
Return_pat_rel
Return_pcn
Return_mod1_1
Return_proc_code_1

MyTexas Covid-19 Houston

New Here? Well, We Look Forward to Helping You!

You have selected:

- No, this will be my first time testing with MyTexas Covid-19 Houston

(or your information didn't pull up and you selected: I tried pulling up my information but it was not found!)

If you have questions, find a MyTexas Covid-19 Houston (MTCH) Team Member and we will be happy to help.

- PAGE 3 -
New Patient Registration

New Patient Registration - Please completely answer all questions
Name of Person Being Tested *

First Name Middle Name Last Name
Birth Date (of the person being tested) -NP *

Month Day Year
Date
Sex / Gender: *

Female Male Other
Address of Person being Tested *

Street Address

Street Address Line 2

City State

Zip Code
Data Name Tested
Data Address
Cell Phone Number (results sent here) *
Please enter a valid phone number.
Data Cell Phone
Contact Email for Person Being Tested (results sent here) *
example@example.com (if no email, put no@email.com - note this limits results communication to cell phone only)
All Adults being tested or Parent(s)/Guardian(s) of non-adults being tested must provide a photo of government identification
Picture Identification: Driver License (Front) |State ID | Passport -NP *

Cancel of
If you are insured, please take front & back picture of your card only (no SSN). If uninsured, enter your Driver's License Number, Passport ID Number, and/or Social Security Number.
Insurance Card (Front) -NP

Cancel of
Insurance Card (Back) -NP

Cancel of
TYPE OF GOVERNMENT ISSUED ID (not needed if uploaded photo ID)
GOVERNMENT ISSUE ID NUMBER # (not needed if uploaded photo ID)
Social Security Number (not needed if uploaded insurance) -NP
Employed in Healthcare?
Resident in Congregated Setting? (apartments, condo, student or faculty housing, park staff housing, transitional housing, and shelters)

Returning Patient Verification

New Patient Registration

Health Questionnaire & Consent To Testing

COVID-19 EXPOSURE

Submission