Edison COVID Testing Registration 12-11-20

Edison Township COVID-19 Testing Registration Form

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

EVENTS: DECEMBER 7, 2020 and DECEMBER 11, 2020, 10 am – 3 pm. Appointment preferred and made at:

1. Edison COVID-19 Testing Registration for 12/07/2020

2. Edison COVID-19 Testing Registration for 12/11/2020

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 in a vehicle and wearing a mask during your scheduled date and time. For support with this form only, contact wellcarecovidtesting@gmail.com.

Township of Edison
100 Municipal Boulevard
Lake Papaianni
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, December 11, 2020 – 10:00 am – 3:00 pm

DRIVE THRU‐TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS

Name	Date	Time		Action
Edison	Friday, December 11	10:00 AM to 10:30 AM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Edison	Friday, December 11	10:30 AM to 11:00 AM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Edison	Friday, December 11	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 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 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, December 11	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 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 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, December 11	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 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 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, December 11	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 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 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, December 11	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 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, December 11	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 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, December 11	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 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, December 11	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 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

Township of Edison100 Municipal BoulevardLake PapaianniEdison, NJ 08817

COVID-19 Testing, Friday, December 11, 2020 – 10:00 am – 3:00 pm

DRIVE THRU‐TESTING EVENT FOR THOSE WITH OR WITHOUT SYMPTOMS

Township of Edison
100 Municipal Boulevard
Lake Papaianni
Edison, NJ 08817

COVID-19 Testing,
Friday, December 11, 2020 – 10:00 am – 3:00 pm

DRIVE THRU‐TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS