COVID-19 Insurance Information Form Please complete the form below for each participant.Are you requesting a PCR test or an Antigen test?*AntigenPCRIs the participant getting tested due to having symptoms and/or having contact with a COVID-19 patient?*YesNoDo you have Christian Care Ministries, Medishare, Tricare, TriWest, or VA Insurance?*YesNoTotalWellness 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*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Name*AETNABlue Cross Blue Shield of NebraskaHealthy BlueHeritage Health - Nebraska Total CareMEDICAMedicareMedicare - RailroadMedicare & Medicare Supplemental PlanMidlands ChoiceUMRUnitedHealthCare (UHC)Other (Please Specify)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*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance Holder's Employer* Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Participant's Relationship to Insured*SelfSpouseDependentInsurance Card Image - Front*Max. file size: 15 MB.Insurance Card Image - Back*Max. file size: 15 MB.Unique IDTotalWellness no longer accepts Christian Care Ministries, Medishare, 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 Christian Care Ministries, Medishare, 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.