Special notes for your tester such as Gate Code, Apt # etc.
Anything our tester needs to know prior to arrival?
Please upload the following now to save time during your appointment.
Insurance Card - Front
Insurance Card - Back
For those uninsured you can fill out a form your tester will provide confirming your uninsured status.
Accepted file types: jpg, gif, png, pdf, Max. file size: 40 MB.
Drop files here or
By confirming and proceeding with your submission you are confirming that you are not covered or enrolled under any private, individual (non-group or COBRA) or group (employer or other organization-sponsored) health insurance plan, any federal health care program (including but not limited to Medicare, Medicaid or TRICARE), nor am I covered under the health insurance of a spouse or parent.
Al confirmar y proceder con su sometimiento está usted confirmando que no está cubierto o afiliado a ningún plan de seguro de salud privado, individual (no-grupal o COBRA), programa de cuidado de salud federal (incluyendo pero no limitado a Medicare, Medicaid o TRICARE), y que tampoco está cubierto bajo algún seguro de salud de un conyugue o pariente.
By signing below you are confirming the information you will provide to be correct and truthful to the best of your knowledge. You are authorizing the information to be submitted for review by the ordering physician. You are authorizing Myhealthsight LLC and it's physician and lab partners to bill your insurance for the services provided and rendered and may be shared to assist for the purpose of billing and processing. All information provided will be used to assist with the billing for provided services.