Castleton University Covid Testing Registration Form If you need assistance with the form, please call 802-468-2928 Ext. 2816 or 2812 Name* Patient's First Name Middle Inital Patient's Last Name Social Security Number* Marital StatusPlease selectSingleMarriedWidowedDivorcedSeparatedRegistered PartnershipPreferred Name Former Name(s) Birth Date* MM slash DD slash YYYY Sex Male Female Mailing 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 County* Home Phone*Cell PhoneWork PhoneEmail* Enter Email Confirm Email Pharmacy Pharmacy Address Insurance InformationPerson responsible for bill Birth date MM slash DD slash YYYY Home PhoneAddress (if different) 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 Name of Primary Insurance Company Subscriber's Name Subscriber's Social Security Number Subscriber's Birthdate MM slash DD slash YYYY Patient's Relationship to Subscriber Policy Number Group Number Co-payment Do you have secondary insurance? Yes No Secondary Insurance InformationName of Secondary Insurance (if applicable) Subscriber's Name Subscriber's Social Security Number Subscriber's Birthdate MM slash DD slash YYYY Patient's Relationship to Subscriber Policy Number Group Number Co-payment IN CASE OF EMERGENCYName of local friend/relative Relationship to patient PhoneI give my permission for Community Health to discuss my COVID test result with the Castleton University Wellness Center.* Yes No Do you have a history of a positive COVID test? Yes No Additional Contact Person Relationship to patient PhoneAddress 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 *Please provide us with an image of your insurance cards for our recordsAccepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.I authorize the release of information, including the diagnosis and copies of records of any treatment of examination rendered to me or my dependent during the period of such care, to third party payers and/or other health practitioners. I agree that this consent constitutes any permission that Community health and medical staff would otherwise be required to obtain under Vermont laws before so using or disclosing my protected health information. I am aware that Community Health privacy practices are further described in the Community Health notice of Privacy Practices. I give my consent for examination diagnostic procedures, medical treatments and surgical procedures including local anesthesia, as prescribed by my physician. I acknowledge that no guarantees have been made to me regarding the results of the examination and or treatment. I authorize and request my insurance company to pay directly to Community Health, benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all service rendered on my behalf, or my dependents in accordance with my health care plan. I understand that this form gives permission for treatment in accordance with the physician’s orders. For the purpose of advancing medical education, I authorize the attendance of healthcare students participating in Community Health Programs. I authorize Community Health to examine, retain, and preserve or dispose of any tissues or specimens removed from my body. I authorize my insurance company or employer to discuss matter related to the payment to claims with Community Health. Electronic Signature* Date* MM slash DD slash YYYY
