COVID-19 Registration

REFUND PROCESSED

Approved By

Approved Date

Date

Who are you registering? *

I am registering for myself to be tested I am registering an entire company to establish testing I represent the HR Department for a previously established account and I am uploading employee/patient demographics I am an S&G Labs Hawaii Employee obtaining registration data

Are you collecting for Hawaii County? (Civic Center in Hilo)

Yes, I am collecting samples for "County" testing No

Lab nexus location:

Name of company:

Your account representative:

Does this submission contain all employees or patients scheduled to be tested?

Yes, the list is conclusive for all staff or patients who are to be tested No, multiple submissions are required to encompass all employees or patients

Have all of the employees or patient confirmed their testing date?

Yes, the list is conclusive for all staff or patients who are to be tested No, testing has been offered to all individuals listed on the sheet but not all individuals have confirmed their appointment

Regarding payment for the individuals listed in the submission:

Bill insurance or CARES Act for all listed individuals. In the case of missing information or incorrect information, please notify our HR department for updates. Bill insurance or CARES Act for listed individuals that have insurance, send an invoice to our finance department for all others. Send an invoice to our finance department for all individuals listed.

In the event the information provided in the submitted document is no longer valid (demographics, contact information, or insurance), requests for updated information can be sent to:

example@example.com

Have there been confirmed cases of COVID-19 amongst the individuals being tested?

Yes, one or more of the employees tested or working for our facility have tested positive for COVID-19. No, our place of business does not have any reported positive COVID019 cases.

File upload for patient demographics *

Browse Files

Max file size for each file is capped at 100MB. Accepted file formats: xls, xlsx, csv, zip

Collection Date

Date Hour Minutes

DISABLED Please choose an option that best describes your symptoms: *

Severe Symptoms Mild Symptoms No Symptoms

Why are you choosing to be tested? *

Non-travel related Travel

Please note: Samples for travel purposes are required to meet certain time restraints. If you are taking this test for travel clearance you MUST choose travel as your reason to be tested to meet the required turnaround time. These tests require pre-payment. All registration forms are checked for pre-payment before analysis. If your registration is entered in error - your sample will not be tested.

Please note: Continuing with registration for travel requires prepayment. *

I understand I will not be refunded for my test if I am tested at one of the County of Hawaii (no cost to you) testing events

You can pre-register directly with us and pay for Travel testing. You will need to schedule a testing appointment at one of our testing locations. You cannot get tested at the County of Hawaii events or with our testing partners if you choose this option. Details to follow.

Testing locations are updated regularly here:

S&G Labs Hawaii Testing Locations

Where will you be tested? *

S&G Labs Hawaii testing location Castle Hospital in O'ahu I am unsure

Which Hawaii County testing site will you attend? *

Kona Civic Center (Saturday 9AM - 12 PM) Hilo Civic Center (Wednesday every week)

County of Hawaii on Hawaii Island is providing "no cost to you" community testing.

Testing is drive-through. Please plan to stay in your car, and wear a face mask when talking with anybody outside your vehicle. It’s helpful to bring your own pen to fill out the form, and easier if you bring a clipboard or hard surface on which to write.

Please bring your insurance card (if you have insurance) as well as a photo I.D. Your insurance will be billed for testing at no cost to you, or the test will be covered by Hawaii County.

Hawaii County officials have said that the cost of testing is being covered via Federal CARES Funding.

For more information about testing, check the testing schedule on the Hawaii County Civil Defense web site,

https://coronavirus-response-county-of-hawaii-hawaiicountygis.hub.arcgis.com/pages/covid-19-testing or call 808-935-3311. Do not proceed with preregistration.

We have several testing partners throughout the State where you can get tested. These partners are the best option if you are traveling from O'ahu or Maui. Please check with the facility directly for costs and schedules associated with testing. Do not proceed with pre-registration

Choose the risk of your exposure to COVID-19 in the last 14 days: *

Confirmed Exposure Unconfirmed Exposure No Exposure

Insurance does not cover travel testing for COVID-19. Payment for travel testing is 100% the patient's responsibility. We do not provide support or billing information for travel testing reimbursement requests.

Continuing registration for travel will require pre-payment for COVID-19 testing.

Kama'aina discounts are available and require an upload of your Hawaii State ID. A discount code will be presented to you at checkout.

Many countries require the passport number to be printed on COVID-19 results for traveler validation. If you are travelling with your passport please enter the number here:

Passport ID

Island *

Name *

First Name Last Name

Date of birth *

Date

Sex *

Male Female

Ethnicity *

Mail Results

Yes - No email address No - Patient will use portal

Email *

Confirmation Email example@example.com

Phone Number *

Is your mailing address the same as your residential address? *

No, I don't live where I receive mail Yes, my mail is delivered to my home

Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code Country

Physical Home Address *

Street Address

Street Address Line 2

City State

Zip Code Country

ID upload *

Browse Files

Please include front and back pictures of an identification card. Examples of this type of identification include: drivers license, state ID, passport, military ID, etc. You can upload multiple separate files.

Were you referred to COVID Free Hawaii/ S&G labs to be tested by an employer, provider, university, or treatment facility? *

Yes, by my employer Yes, by my school Yes, by my doctor Yes, by a treatment facility Yes, by a company not listed No, I was not referred by a company to be tested. Yes, by Project Vision

Is the facility that referred you registered with an account to view your results? *

Yes No I'm not sure

Name of the company/employer/school that referred you: (Example: Urgent Care of Hawaii, University of Hawaii, etc) *

Choose a payment option to continue *

Bill my active health insurance I have NO active health coverage and may be covered for testing under the CARES Act (uninsured only) My employer is paying for my test

Company Account Number: *

You must have the correct account number to proceed with registration. Please contact your HR department representative for your company account number. S&G Labs Hawaii / COVID Free Hawaii is unable to provide this information.

Company Name *

HR representative name *

Who should we call to confirm and collect payment?

HR/Management Email *

example@example.com for the management or HR department covering the cost of your test

HR/Manager Phone Number *

COUNTY: Choose a payment option to continue *

Bill my active health insurance I have NO active health coverage and may be covered for testing under the CARES Act (uninsured only) Non-US citizen Out of network insurance

Do you have in-network insurance? (in-network insurances include: AARP, AETNA, Alohacare, CIGNA, HMSA, HMAA, HMA, Humana, Kaiser, MDX, Medicare, PSWA, Ohana, and United Healthcare) *

Yes No

If you have no active health coverage, your test cost may be covered by the COVID-19 Uninsured Program with medical necessity at no cost to you. If you attest that you have no active health coverage, please initial here *

Social Security Number *

Your valid social security number is required by the CARES act to cover COVID-19 testing for those without insurance. Your social security number will not be used for any other purpose and is not required if you have insurance.

TEXT: Primary Insurance Company Name:

If you have a Medicare replacement/advantage plan, please provide this plan info

Primary Insurance Company:

If you have a Medicare replacement/advantage plan, please provide this plan info

UHA requires a referral and encounter notes to cover the cost of COVID-19 testing. *

I will visit my provider and have them refer me to be tested with S&G Labs Hawaii. I would like to continue registration at a cash rate of $150.00 I have a referral from my provider to upload

Policy#/Subscriber ID:

Use N/A if uninsured

Provider Referral/Encounter Note *

Browse Files

acceptable file formats: pdf, doc, docx, txt, rtf, html, zip, jpg, jpeg, png, gif

Secondary Insurance Company:

If you have a Medicare replacement/advantage plan, please provide this plan info, or N/A

Secondary Policy#/Subscriber ID:

Use N/A if uninsured

Any Additional Insurance Information:

Please provide as much info as you can to expedite the processing of your test.

Insurance Card Upload *

Browse Files

Please include front and back pictures of your insurance card. You can upload multiple separate files.

Screening questions to determine medical necessity

You will be asked a series of questions to determine medical necessity. Please read each question carefully and answer them truthfully. Priority testing will be given to patients experiencing symptoms of COVID-19 currently and in the past two weeks. Based on insurance coverage patients that do not meet medical necessity requirements may not be eligible for covered testing. If you do not meet the required medical necessity for coverage you are eligible to be tested for a cash rate.

Which health conditions apply? *

In the last two weeks have you experienced symptoms of coughing? *

Yes No

In the last two weeks have you experienced symptoms of fever? *

Yes No

In the last two weeks have you experienced symptoms of shortness of breath? *

Yes No

In last two weeks have you experienced symptoms of tiredness / fatigue? *

Yes No

In the last two weeks have you experienced symptoms of runny nose? *

Yes No

In the last two weeks have you experienced symptoms of loss of taste/smell? *

Yes No

Are you a resident of Hawaii with a Hawaii based residential address? *

Yes No

Are you a student at a two or four year university? *

Yes No

Student discount code: STUDENT

Student ID Upload *

Browse Files

Please include the front of your student ID

Kama'aina discount code: KDD20135

COVID ABN

Advance Beneficiary Notice of Non-coverage

COVID19 tests are covered by insurance with medical necessity including possible exposure and/or symptoms, excluding travel required testing. By signing this form, you are confirming that you understand and agree that you do not meet medical necessity for testing coverage and wish to proceed and to pay the fee of $150.00. In some cases, we may be sending a claim to your insurance company to inform them that we have billed you for the testing with an ABN form on file as insurance agreements stipulate. We will not be attempting to bill your insurance. You may receive an EOB from your insurance company as part of this process. Please note that the EOB is not a bill.

Purchase Options *

COVID-19 PCR Test $ 150.00

This tests for a current COVID-19 infection

Enter coupon

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Consent Obtained By: *

Electronically signed by: *

First Name Last Name

Signature: *

Clear

Exposure DIAG

DIAG Cough

DIAG Fever

DIAG Breath

DIAG fatigue

DIAG runny nose

DIAG taste

DIAG Type 2

DIAG Smoke

DIAG Asthma

DIAG Heart

DIAG Liver

DIAG Preg

DIAG COPD

DIAG obesity

DIAG kidney

DIAG Heart

DIAG Immune

DIAG HIV

DIAG Arthritis

Diagnosis codes