Pascack COVID-19 Testing 10 28 21

Bernards Township COVID-19 Testing Registration Form

Pascack Valley Regional High School District
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 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.

(201) 358-7006

Pascack Valley Regional High School District

Hillsdale School District

Woodcliff Lake School District

Demarest

Emerson

COVID-19 Testing – Walk-Up Event
Thursday October 28, 2021 – 03:30 pm – 5:30 pm

Name	Date	Time		Action
Pascack	Thursday, October 28	03:30 PM to 04:00 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 this test. 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
Pascack	Thursday, October 28	04:00 PM to 04:30 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 this test. 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
Pascack	Thursday, October 28	04:30 PM to 05:00 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 this test. 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
Pascack	Thursday, October 28	05:00 PM to 05:30 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 this test. 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.