Covid Test Form

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Your E-Mail Address

Last Name

Legal First Name

Social Security Number

Birth Date

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Student/Employee ID Number

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Cell Phone Number

Street address

City

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Insurance Registration

Insurance Company Name

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Member ID / Policy Number

Group Number (if applicable)

Policy Holder's Name

Policy Holder's birth date

Affirmation for Consent for Medical Care & Release of Information By checking this box you affirm that you have read the above Consent for Medical Care & Release of Information, as well as having read and understand the Patient Bill of Rights

Campus Health Services

Cardinal Station - Belknap

215 Central Ave., Suite 110
Louisville, KY 40208
P(502) 852-6479
F(502) 852-0660

HIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices (en español)
Notice of Nondiscrimination

Health Care Outpatient Center - HSC

401 E. Chestnut., Suite 110
Louisville, KY 40202
P(502) 852-6446
F(502) 852-6649

Appointments - Belknap: (502) 852-6479
Appointments - HSC: (502) 852-6446
Insurance Advocate: (502)-852-6519
Immunization Coordinator: (502) 852-2708

Campus Health Services programs, services and resources are open to all eligible students, faculty (when applicable), and staff (when applicable), regardless of race, color, national origin, sex, disability, or age.