Brodstone Memorial Hospital Covid Testing

Please complete the form below for each participant.
Participant Name*
First Last Suffix
Participant Date of Birth*
Does the participant currently have any COVID-19 symptoms such as fever or chills, difficulty breathing, fatigue, body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea?*
Does the participant have health insurance?*
Insurance Company Name*
Insurance Company Name*
Insurance Company Phone Number*
Located on the back of your card.
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*
Participant's Relationship to Insured*
Insurance Card Image - Front
Max. file size: 5 MB.
Insurance Card Image - Back
Max. file size: 5 MB.
Unique ID