COVID-19 Testing Request

This form is not to request anitbody testing.

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.
Testing is available regardless of insurance status *
* 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.
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.
Monday-Thursday 11am - 7pm
Friday & Saturday 8am-4pm
Sunday closed. No appointments will be accepted/scheduled.
Please choose a date that is at least one day in advance.

Patient Information

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Last
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.
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Last

Home Address*

Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code

Email*

Enter Email
Confirm Email





If applicable, the lab running the test will bill the insurance company.

Please enter only the carrier name. There is a 25 character limit.

Guarantor Information

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.

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Last
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code















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