COVID-19 Testing Request
Testing by appointment only
This form is not to request anitbody testing.
Antigen tests are Point-of-Care tests that help healthcare providers rapidly identify COVID-19 infection in symptomatic individuals. Use of antigen testing should ideally occur within 7 days of when symptoms develop.
This form is solely used by NH Homeland Security and Emergency Management
to coordinate the scheduling of COVID-19 testing in conjunction with the
New Hampshire National Guard. Your information will be kept confidential
and only used for diagnostic and tracking purposes. In filling this form
out you are voluntarily sharing this information for the purpose of your
sample collection. Information on this site will be shared with the New
Hampshire Division of Public Health Services for public health purposes.
Under the authority provided by the Families First Coronavirus Relief Act (FFCRA), New Hampshire has opted to implement a new Medicaid eligibility group to cover COVID-19 testing services for individuals who are uninsured or have certain limited health coverage. Individuals must apply and qualify for this testing group and will need to provide a social security number and self-attest to being a resident of New Hampshire and either a US Citizen or having a qualifying immigration status on the application. There is no income or resource test for this group. Covered services include only COVID-19 testing and testing-related services, including anti-body (serological) testing. Please note that this Medicaid group does not cover treatment or medication for COVID-19, and does not cover any other services other than the COVID-19 testing services. If you would like to find out if you are eligible for a different Medicaid group that covers more than COVID-19 testing services, please visit NH EASY by clicking this link
https://nheasy.nh.gov/#/. You will find information about other DHHS programs you may be eligible for as well.
Note that you should still request a test and follow the instructions once your test is scheduled while your Medicaid application is being processed.
NOTE: Go to
COVID-19 PCR Testing Options for additional sites not listed below.
* If you are interested in coverage for COVID-19 testing, there is a new Medicaid plan that you may be eligible for; select the checkbox below to complete a short application. Further information can be found here
Medicaid Testing FAQ's.
Information for providers can be found hereGuidance for Providers on the COVID-19 Medicaid Testing Eligibility Group.
The last day of Covid-19 fixed testing sites is Saturday, June 19, 2021. Please visit
COVID-19 PCR Testing Options for other testing locations.
Test Type*
Testing Location First Choice*
Testing Location Second Choice*
Testing Location Third Choice*
If you indicate you cannot travel to any of the above meeting locations, a Department of Heath and Human Services personnel will be in contact with you. Please continue to fill out the rest of the form.
Please note that the testing sites have changed hours of operation when selecting your appointment time.
Concord location is now located inside the old Sears building.
New hours of operation for Concord are as follows
Monday 12pm - 6pm
Tuesday CLOSED
Wednesday 12pm - 6pm
Thursday CLOSED
Friday 12pm - 6pm
Saturday 8am - 2pm
Sunday closed. No appointments will be accepted/scheduled.
Londonderry location is moving to Lord & Taylor at 99 Rockingham Blvd, Salem effective Wednesday, 3/31. Best access is through the parking garage on the 2nd floor.
Hours of operation for Salem are as follows
Monday 12pm - 6pm
Tuesday CLOSED
Wednesday 12pm - 6pm
Thursday CLOSED
Friday 12pm - 6pm
Saturday 8am - 2pm
Sunday closed. No appointments will be accepted/scheduled.
We can’t guarantee that your test results will be available in time for your travel dates.
Requested date*
Please choose a date that is at least one day in advance.
Preferred Time Slot #1*
Preferred Time Slot #2*
Preferred Time Slot #3*
Patient Information
Name*
Driver License*
Date of Birth*
Age
If you are under 18 years old, parent or guardian consent will be required to be tested. Please provide contact information for a parent or guardian below.
Parent/Guardian Name*
Parent/Guardian Phone Number*
Home Address*
Street Address
Address Line 2
State / Province / Region
Enter Email
Confirm Email
Cell phone provider*
Do you need communication access or language assistance services such as an interpreter for your testing appointment?
Sex*
Ethnicity*
Race*
Have you traveled in the past two weeks?*
If applicable, the lab running the test will bill the insurance company.
Insurance Carrier
Please enter only the carrier name. There is a 25 character limit.
Policy #*
Group #*
Guarantor Information
Are you listed as the Guarantor for your insurance?*
The Guarantor is the individual listed on your insurance plan as the payer for insurance premiums. If you would be responsible for paying any bill that your insurance issues, select "Yes" below. If someone besides yourself would be responsible for any bill that your insurance issues, please select "No" and enter that persons information below. Guarantor examples would be a spouse, parent, guardian, etc.
Guarantor Name*
Guarantor Address*
Street Address
Address Line 2
State / Province / Region
Phone Number*
Guarantor relationship to patient*
Indicate if any of the following apply to you: