Sacred Heart Church Covid 19 Registration 11 29 20

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

Sacred Heart Church

12 Terrace Avenue

Rochelle Park, NJ

COVID-19 Testing,
Sunday, November 29, 2020 – 1:30 am – 4:30 pm

DRIVE THRU‐TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS

Name	Date	Time		Action
Sacred Heart Church	Sunday, November 29	01:30 PM to 02:00 PM	Check Availability	The maximum number of entries exceeded. Please choose another slot.
Sacred Heart Church	Sunday, November 29	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
Sacred Heart Church	Sunday, November 29	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
Sacred Heart Church	Sunday, November 29	03:00 PM to 03:30 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
Sacred Heart Church	Sunday, November 29	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 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
Sacred Heart Church	Sunday, November 29	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 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

Sacred Heart Church

12 Terrace Avenue

Rochelle Park, NJ

COVID-19 Testing, Sunday, November 29, 2020 – 1:30 am – 4:30 pm

DRIVE THRU‐TESTING EVENT FOR THOSE WITH OR WITHOUT SYMPTOMS

COVID-19 Testing,
Sunday, November 29, 2020 – 1:30 am – 4:30 pm

DRIVE THRU‐TESTING EVENT
FOR THOSE WITH OR WITHOUT SYMPTOMS