LA RC & Group Homes Covid-19 Community Testing Registration
ZERO out-of-pocket cost to ALL community members. Please provide complete insurance information if insured (proof of insurance required), or request application for presumptive eligibility if uninsured.

"Healthcare providers may share patient information with anyone as necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public consistent with applicable law and the provider's standards of ethical conduct." (COVID-19 Bulletin at p.4, citing 45 C.F.R. § 164.512(j)).
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Site Location *
Test Date *
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Last Name *
First Name *
Middle Initial
Date of Birth *
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Gender Identity *
Sexual Orientation *
Phone number *
Email (recommended)
Address (include # street, city, state) *
Address cont'd (Zip Code) *
Race *
Ethnicity *
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