Carson Patient Forms

Complete the forms below to confirm your appointment for COVID-19 testing.

This website is SSL secure and all of your personal information is protected under HIPAA Compliance.

 

Welcome to US Health Clinics

US Health Clinics is a licensed medical clinic NPI #1962044479. All patient information is protected according to HIPAA compliance.

As a new patient, it is necessary that you complete your patient information forms, with all of your personal & medical information, just as you would at every other doctor's office or any hospital.

Before You Get Started:

You will need to upload a photo of your Insurance Card (front & back).

You will also need to upload a photo of your Driver License or State ID.

Your appointment cannot be confirmed until the following forms are complete in full.

NOTE: If your tests are positive for SARS-CoV2, the virus that causes COVID-19, your results will also be forwarded to the CDC or appropriate reporting agency.

Everyone at US Health Clinics, wishes you good health.


Patient Identification and Insurance Information

If no ID enter SS#. Required to receive results.
Check all that apply.

Insurance Coverage:

March 18, 2020 Congress passed a law that Coronavirus treatment is required to be covered by all insurance plans. If you have insurance you must provide the information to receive your test results.

US Health Clinics.org is an “out-of-network provider”. Your insurance company will reimburse us for the cost of your test and results. If you do not have any insurance, the CARES Act will cover the cost for your COVID-19 test. This test will remain 100% free to everyone.


Please upload an image file or .PDF of your ID or Driver License and the front and back of your insurance cards, if you have insurance. This is required to receive your test results.

Parents please submit your insurance information for your minor children.

If you cannot upload a picture below, text the pictures to us using your phone's text messaging. In the Send To: phone number field type: missingdocs@ushealthfairs.org.



Check that all of you answers are complete.

Then, click the "Continue" button and the signature page will appear.

EVALUATE

TEST

TREAT

Preventive Healthcare
Saves Lives

US Health Clinics

Medical Outreach in Your Community

Preventive Health Education is Our Mission

Volunteers & Medical Professionals Providing Education

(805) 625-9245

info@ushealthfairs.org

3751 Motor Ave., Suite 173, Los Angeles, CA 90034