PruittHealth Patient Test Registration Form

PruittHealth Patient Test Registration Form
The following screening questions are used to determine the medical appropriateness for your COVID-19 testing for most insurance health plans.

Patients with health insurance should not have out-of-pocket cost for diagnostic, medically appropriate COVID-19 testing. A COVID-19 test is considered diagnostic and medically appropriate if :
- You have symptoms consistent with COVID-19, regardless of vaccination status, or
- You are testing as a result of contact tracing efforts, or
- You were exposed to someone with a confirmed or suspected case of COVID-19.
If the above does not apply to you, a screening test is available for $165, which is payable by credit card.
Have you been asked or referred to get tested by a health care provider?*

YesNo
Have you tested positive for COVID-19 in the past 90 days?*

YesNo
Have you experienced any symptoms in the last 14 days?*

YesNo

Are you experiencing any of the following symptoms?