Language:

Belleville, NJ COVID-19 Test Registration

There is no cost to you for this test and it is open to everyone. If you have medical insurance, it fully covers the cost with no co-pay. If you don't have insurance, the CARES ACT covers testing with your Social Security Number. You may receive a statement from your insurance company - an explanation of Benefits (EOB) - but it is not a bill and there is nothing to pay even if a balance is indicated. All information is confidential under HIPAA guidelines. For questions about this test event, you may email .

Location:

Date and Time: (Please select an open time)

First Name:

Last Name:

Date of Birth:

Gender:
Male Female

Address:

City:

State:

Zip Code:

Mobile Phone:

Email: (Optional but recommended)

Primary Insurance:

Subscriber ID:

Group Reference:

Secondary Insurance: (Optional, if covered)

Subscriber ID:

Group Reference:

Primary Physician: (Optional)

Physician Phone: (Optional)

Please let us know the following to help prioritize your test -

Current Symptoms:

Current Medical History:

Asthma or chronic lung disease
Cancer (current or previous)
Cirrhosis of the liver

Diabetes
Cough
Kidney failure or ESRD

Obesity (BMI over 30)
Serious heart condition
Weakened immune system

Additional Questions:

I have been exposed to someone who tested positive

I have been prioritized for testing by a medical professional

I work in health care or work/live a setting where the risk of COVID-19 transmission is high

Copy of Photo ID and Insurance Card: (Optional)
Taking a photo of your state-issued ID and insurance card (front and back) will save time at check-in.

License / ID Card

Insurance Front

Insurance Back

Acknowledgement and Authorization to Test:

I acknowledge that I have answered these questions truthfully to the best of my knowledge.

I additionally provide consent for testing and reporting of results by electronic and telephonic means, including as a parent or legal guardian to minors that I may have registered.

Belleville, NJ COVID-19 Test Registration

Registration Confirmed

Cancellation Confirmation

Registration Cancelled