COVID-19 Registration

EXPORT Type

EXPORT Race

EXPORT Reason

EXPORT Passport

EXPORT DX

EXPORT Organization ID:

Lab nexus location:

Approved By

Approved Date

Date

Who are you registering? *

I need to be tested or a family member needs to be tested I am an administrator registering 5 or more employees to be tested

Expected Sample Volume

Thank you for choosing to be tested with S&G Labs Hawaii.

It appears you have decided to set up an EMPLOYER account for covid testing instead of registering for an INDIVIDUAL covid test for yourself and/or your family. EMPLOYER accounts are reserved for businesses that wish to receive results for their employees with a volume of staff greater than 5.

EMPLOYER registration does not create an order in our system for a person to be tested. This registration ONLY sets up the shell account needed by employers to access results.

Please return to the registration menu above and choose the option "I am registering for myself to be tested" to proceed with registering for a COVID test. Each person in your group or family will need to register to be tested individually.

PLEASE NOTE: Samples tested Saturday will be received and tested by S&G Labs Hawaii the following Monday. Please allow up to 72 hours to receive your COVID-19 test results if you are tested on Saturday. *

I understand that if I am tested on Saturday my sample will not be received by the laboratory until the following Monday and I may not receive my results until Monday evening.

Why are you choosing to be tested? *

Exposure Travel Work Symptoms

Did your employer give you an account number to use for your test? *

Yes, my employer gave me an account number to use for this test No, I do not have an account number

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. YOU WILL NOT BE ABLE TO SUBMIT THIS FORM WITHOUT A VALIDATED ACCOUNT NUMBER

Company Name *

Patient ID:

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 *

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

Confirmed Exposure Unconfirmed Exposure No Exposure

Are you currently or in the last 14 days have you been experiencing symptoms of COVID-19 (cough, fever, shortness of breath, tiredness/fatigue, loss of taste and smell): *

Yes, I have symptoms of COVID-19 No I am not experiencing symptoms of COVID-19

Based on your answers you are not eligible to be tested

Testing locations are updated regularly here:

S&G Labs Hawaii Testing Locations

Where will you be tested? *

S&G Labs Hawaii - Kona Big Island Pain Center - Hilo I am unsure Other

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)

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

Based on your answers continuing registration will require pre-payment for COVID-19 testing. This payment is not refundable after your sample has been collected.

We do not provide support or billing information including NPI/Tax ID) for travel testing reimbursement requests.

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

Race *

Mail Results

Yes - No email address No - Patient will use portal

Email *

Confirmation Email example@example.com

Phone Number *

This phone number will be contacted in the event of a positive result.

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

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 active insurance. Your social security number will not be used for any other purpose and may be used to submit a claim under the CARES act if your insurance is no longer active.

EXPORT Insurance ID:

EXPORT Primary Insurance 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

Policy#/Subscriber ID:

Use N/A if uninsured

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.

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: STU2021

Student ID Upload *

Browse Files

Please include the front of your student ID

Kama'aina discount code: KDD27779

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.

Please note: Continuing with registration requires prepayment. *

I understand I will not be refunded for my test once it has been collected

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