Edison COVID 19 Testing 02-12-21

Edison Township COVID-19 Testing Registration Form

WELLCARE, TCCM in Partnership with Edison Township will be Conducting COVID-19 COMMUNITY DRIVE THRU-TESTING

Please fill out the following information to complete your registration. With medical insurance, there is no cost to you for the COVID-19 test. We will only perform diagnostic medical services covered by your medical insurance. You will receive a statement from your insurance company – an explanation of Benefits (EOB) – which will itemize the services received, but it is not a bill. At this time, we are not able to support self-pay registrations.

Please note that all participants are required to arrive at the test location wearing a mask during your scheduled date and time. For support with this form only, contact wellcarecovidtesting@gmail.com.

Save Time In Line - Download and fill out these 2 forms and bring them along with you to your test.

1. Assignment of Benefits Form [PDF]
2. Covid Specimen Intake Form [PDF]

Uninsured, Please Note:

Due to the lack of sufficient funding for the HRSA COVID-19 Uninsured Program, our COVID-19 testing clinics will bill individuals without health insurance $75 per COVID-19 test.

Township of Edison
Minnie B Veal Recreation Center
1070 Grove Ave.
Edison, NJ 08817

All participants will need to have their original state issued photo ID and all medical insurance cards (copies will not be accepted).

COVID-19 Testing,
Friday, February 12, 2021 ‐ 10 am – 3 pm

WALK-IN TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS

Name	Date	Time		Action
Edison	Friday, February 12	10:00 AM to 10:30 AM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	10:30 AM to 11:00 AM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	11:00 AM to 11:30 AM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	11:30 AM to 12:00 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	12:00 PM to 12:30 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	12:30 PM to 01:00 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	01:00 PM to 01:30 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	01:30 PM to 02:00 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	02:00 PM to 02:30 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized
Edison	Friday, February 12	02:30 PM to 03:00 PM	Check Availability	Δ First Name Last Name Date of Birth Gender Male Female Address City State Zip Code Mobile Phone Email Primary Insurance Name Subscriber ID Group Reference (If you do not have a Group number put in NA) Secondary Insurance (If Covered) Subscriber ID Group Reference Primary Physician Physician Phone Current COVID-19 Symptoms Exposed to someone tested positive Fever Fatigue Dry Cough Difficulty Breathing Other Flu-Like Symptom No Symptoms Checkbox Field I authorize WellCare TCCM to release and process information to insurance carriers regarding any illness/treatment; also, to allow photocopy of my signature to process insurance claims for lifetime. This will remain until revoked by me in writing. All medical services requested from WellCare TCCM for myself and/or dependents makes me fully financially responsible for any/all charges incurred for all the services authorized

Wellcare COVID-19 Testing Service

WellCare provides New Jersey Municipalities and Institutions with free COVID-19 Testing Services.

Save Time In Line - Download and fill out these 2 forms and bring them along with you to your test.

Uninsured, Please Note:

Township of EdisonMinnie B Veal Recreation Center1070 Grove Ave.Edison, NJ 08817

COVID-19 Testing, Friday, February 12, 2021 ‐ 10 am – 3 pm

WALK-IN TESTING EVENT FOR THOSE WITH OR WITHOUT SYMPTOMS

Wellcare COVID-19 Testing Service

Township of Edison
Minnie B Veal Recreation Center
1070 Grove Ave.
Edison, NJ 08817

COVID-19 Testing,
Friday, February 12, 2021 ‐ 10 am – 3 pm

WALK-IN TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS