COVID-19 Insurance - TotalWellness

COVID-19 Insurance Information Form

Please complete the form below for each participant.
Are you requesting a PCR test or an Antigen test?*
Is the participant getting tested due to having symptoms and/or having contact with a COVID-19 patient?*
Do you have Tricare, TriWest, or VA Insurance?*
TotalWellness will only submit your claim to insurance if the test is deemed medically necessary. Please visit https://login.registermytime.com/tw/covidtesting to schedule an appointment and pay online or bring $100 cash to your appointment to pay for your test.
TotalWellness will only submit your claim to insurance if the test is deemed medically necessary. Please visit https://login.registermytime.com/tw/pcrcovidtesting to schedule an appointment and pay online or bring $219 cash to your appointment to pay for your test.
Participant Name*
First Last Suffix
Participant Date of Birth*
Participant Sex*
Participant Phone Number*
Participant Email Address*

The confirmation email will be sent to this email address.
Participant Address*
Street Address Address Line 2 City State ZIP Code
Insurance Company Name*
If you have Medicare and/or a Medicare supplemental plan, we need your Medicare card and number uploaded, as we will run the test through Medicare first.
Insurance Company Name*
Insurance Company Phone Number*
Member ID*
Group ID*

If you only have one ID number on your card, please list the same ID number under both the Member ID and the Group ID.
Group Name*
Primary Insurance Holder's Name*
First Last Suffix
Primary Insurance Holder's Date of Birth*
Primary Insurance Holder's Employer*
Employer Address
Street Address Address Line 2 City State ZIP Code
Participant's Relationship to Insured*
Insurance Card Image - Front*
Max. file size: 15 MB.
Insurance Card Image - Back*
Max. file size: 15 MB.
Unique ID
TotalWellness no longer accepts Tricare, TriWest, or VA Insurance. Please visit https://login.registermytime.com/tw/covidtesting to schedule an appointment and pay online or bring $100 cash to your appointment to pay for your test.
TotalWellness no longer accepts Tricare, TriWest, or VA Insurance. Please visit https://login.registermytime.com/tw/pcrcovidtesting to schedule an appointment and pay online or bring $219 cash to your appointment to pay for your test.