COVID-19 At-Home Test Kit Survey

First Name

Last Name

Date of Birth Year

Date of Birth Month

Date of Birth Day

Gender

Phone

Your Address

Address 1

Address 2 (If needed)

City

State

ZIP code

Shipping Address (your kit will be shipped to this address)

Shipping Address 1

Shipping Address 2 (if needed)

Shipping City

Shipping State

Shipping ZIP code

Insurance information

Primary insurance

Insurance provider if not found in the list

Subscriber ID / Member ID

Group number (If applicable)

Are you the primary insurance member?

Yes, I am the primary insurance member. I am on my spouse's/domestic partner's plan. I am on another person's plan.

Consent

I understand that by submitting this COVID-19 Test (At-Home Kit) request with my associated health insurance information or by requesting payment from governmental funds set aside for COVID-19 services provided to the uninsured, I consent to information about my testing and results being shared with the health insurer or government agency paying for my testing for purposes of payment, treatment, and/or healthcare operations, and as otherwise described in Empire City Laboratory HIPAA & Privacy Policy.

Telephone

Email Address

Corporate Headquarters

COVID-19 At-Home Test Kit Survey

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