COVID-19 Insurance Information Form Please complete the form below for each participant.Is the participant getting tested due to having symptoms and/or having contact with a COVID-19 patient?*YesNoAre you requesting a PCR test or an Antigen test?*AntigenPCRInsurance companies may not cover tests unless the participant has symptoms or has been in contact with a COVID-19 patient. Since the participant has indicated that they do not have symptoms nor have they been in contact with a COVID-19 patient, we ask that you pay out of pocket for this COVID-19 test by either bringing $100 cash to your appointment or by paying in advance online. You can continue on with the appointment process by visiting https://login.registermytime.com/tw/covidtesting.Participant Name* First Last Suffix Participant Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant Sex*FemaleMaleParticipant Phone Number*Participant Email Address* The confirmation email will be sent to this email address.Participant Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Name*AETNABlue Cross Blue Shield of NebraskaMEDICAMedicareMidlands ChoiceTriWestUnitedHealthCare (UHC)Other (Please Specify)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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance Holder's Employer*Employer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Participant's Relationship to Insured*SelfSpouseDependentInsurance Card Image - FrontInsurance Card Image - BackUnique ID