Wentworth-Douglass Hospital Covid Testing Form

The Wentworth-Douglass Hospital Drive-thru COVID testing request is for testing only, and not clinical evaluation.

The Drive-thru COVID testing personnel, Wentworth Health Partners, Wentworth-Douglass Hospital, Mass General Hospital, and Mass General Brigham do not offer, and are not responsible for, clinical care when scheduling or performing the test.

Furthermore, once results are available, ongoing care and advice is the responsibility of the patient to seek.

I agree, please continue...

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Your appointment will be scheduled 3 days prior to your procedure, to ensure timely test results.

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Please follow the instructions at the end of this questionnaire to be directed to the simple NH Easy Medicaid application for testing coverage.

You are about to submit the following information:

Currently Have a WDH Provider?:

Are you experiencing any symptoms you are concerned might be COVID-19?:

Date your symptoms began:

Reason for your request to be tested for COVID-19:

Date of the scheduled procedure:

DOB:

Name:

Email address:

Phone number:

Do you have health insurance coverage?:

Insurance Provider:

Are you interested in applying for Medicaid coverage specifically for COVID-19 testing services?:

Please review your information before submitting. If you need to correct any of the above information, please use the back button.

Thank you for submitting your request COVID-19 testing at the Wentworth-Douglass Hospital Drive-thru. Our team will review your request and call you to schedule the test.

Thank you for submitting your request for COVID-19 testing at the Wentworth-Douglass Hospital Drive-thru. Our team will review your request and call you to schedule the test.

Please follow the link below to be directed to the simple NH Easy Medicaid application for testing coverage.

If you choose not to fill out and/or submit the application electronically, you may print out the application, sign it, and either e-mail, fax or mail it back to the Department of Health and Human Services.

If you have any questions about this Medicaid testing program, please call (603) 271-7373.
https://nheasy.nh.gov/#/uninsured/o/uninsured-start

In order to schedule a COVID test, please contact your Primary Care Physician.