Paramus COVID Testing Registration-01-16-21

Paramus COVID-19 Testing Registration Form

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 test location in a vehicle and wearing a mask during your scheduled date and time. For support with this form only, contact info@wellcaretccm.com.

Test Results

Anyone who tests positive will receive a phone call from our office with their results. Anyone looking for their results, please send an email to WELLCARECOVIDTESTING@GMAIL.COM

Save Time In Line - Download and fill-out these 3 forms and bring them along with you to your test.

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

Paramus DPW Building
Carlough Drive
Paramus, NJ 07652

COVID-19 Testing,
Saturday, January 16, 2021 ‐ 9:00 am ‐ 4pm

Name	Date	Time		Action
Paramus	Saturday, January 16	09:00 AM to 09:30 AM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Paramus	Saturday, January 16	09:30 AM to 10:00 AM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Paramus	Saturday, January 16	10:00 AM to 10:30 AM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Paramus	Saturday, January 16	10:30 AM to 11:00 AM	Check Availability	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
Paramus	Saturday, January 16	11:00 AM to 11:30 AM	Check Availability	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
Paramus	Saturday, January 16	11:30 AM to 12:00 PM	Check Availability	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
Paramus	Saturday, January 16	12:00 PM to 12:30 PM	Check Availability	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
Paramus	Saturday, January 16	12:30 PM to 01:00 PM	Check Availability	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
Paramus	Saturday, January 16	01:00 PM to 01:30 PM	Check Availability	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
Paramus	Saturday, January 16	01:30 PM to 02:00 PM	Check Availability	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
Paramus	Saturday, January 16	02:00 PM to 02:30 PM	Check Availability	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
Paramus	Saturday, January 16	02:30 PM to 03:00 PM	Check Availability	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
Paramus	Saturday, January 16	03:00 PM to 03:30 PM	Check Availability	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
Paramus	Saturday, January 16	03:30 PM to 04:00 PM	Check Availability	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. Call (201) 880-8112

Paramus DPW BuildingCarlough Drive Paramus, NJ 07652

COVID-19 Testing, Saturday, January 16, 2021 ‐ 9:00 am ‐ 4pm

Wellcare COVID-19 Testing Service

Paramus DPW Building
Carlough Drive
Paramus, NJ 07652

COVID-19 Testing,
Saturday, January 16, 2021 ‐ 9:00 am ‐ 4pm