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

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 -

We need your help to verify your identify:

• First 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) - if your name isn't found, ensure you don't have a space after your name entries

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 -

All Adults being tested or Parent(s)/Guardian(s) of non-adults being tested must provide a photo of government identification

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.

MyTexas Covid-19 Houston 

Almost Finished!

This is the Health Questionnaire & Submission Page

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

By signing this form, I understand the following: 

The laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I have the right to withhold or withdraw my consent to the use of telemedicine duirng my care at any time, without affecting my right to future care or treatment. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be in other areas, including out of state.  

I acknowledge that I have been informed of my rights under the Health Information Protection and Portability Act (HIPAA), I understand that I may request copies of this information and rights any time. 

I hereby authorize MyTexas Covid-19 Houston, to use HIPAA-compliant telecommunication for evaluating, testing and diagnosing my medical conditions.

The date and time listed below will be the timestamp for your submission (no need to change this, it cannot be edited).