MILLTOWN PHARMACY COVID 19 TESTING

On March 22, 2022 at 11:59 pm ET, the HRSA COVID-19 Uninsured Program will stop accepting claims for testing and treatment due to a lack of sufficient funds
COVID-19 Testing

Appointment and Consent Form
Type of Test

Rapid Antigen Test (Results in 30 minutes) $90 Rapid FLU & COVID-19 Antigen Test (Results in 30 minutes) $110 RT PCR Test (Results in 24-48 hours) (COVID Exposure) Free 2-HOUR RT-PCR Test (Results in 2 hours,Most commonly used for Travel) $200 Antibody Test (Results in 2 hours, checks if you HAD COVID before) $70
Type of Test

Antibody Test (Results in 2 hours, checks if you HAD COVID before) $70 Rapid Antigen Test (Results in 30 minutes) $90 Rapid FLU & COVID-19 Antigen Test (Results in 30 minutes) $110 Rapid RT-PCR Test (Results in 2 hours, Most commonly used for Travel) $200
Lab-restricted Testing

RT-PCR Test (For COVID Exposure/symptoms only) FREE
Test Appointment
Lab-restricted RT-PCR Test Appointment
Name *

First Name Last Name
Birthdate *

Month Day Year
Gender *

Female Male Other
Cell Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to get FREE At-home Tests (up to 8 tests) if covered by your insurance? *

Yes No
Race *

African American or Black American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander White Other Do Not Wish to Answer
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Do Not Wish to Answer
Are you symptomatic? *

Yes No Unknown
Type of Vehicle you will be in at curbside? (PLEASE MAKE SURE TO INCLUDE MAKE, MODEL AND COLOUR) *
We perform all tests curbside.
Do you have insurance? *

Yes No
Please remember to bring in a photo ID and Insurance Card when you come in for your test.
On March 22, 2022 at 11:59 pm ET, the HRSA COVID-19 Uninsured Program will stop accepting claims for testing and treatment due to a lack of sufficient funds.

Our out of pocket costs for Rapid Antigen Test is $90 and for RT-PCR test is $200.
Insurance Card Front Photo (only required if booking free test)
Insurance Card Back Photo (only required if booking free test)
Social Security Number
Required if you do not have insurance and booking FREE RT-PCR Test.
Refund Policy: There are no refunds for COVID testing once you confirm payment. You can reschedule to another date and time or we can offer you a free test voucher, should you miss your scheduled testing appointment.
I agree, To be fully financially responsible for the full cost of this COVID test(s) as listed above. I attest that I am not booking the test for travel purposes. I understand that any payment for which I am financially responsible for is due prior to the time of service, for which Milltown Pharmacy will provide receipt of such invoice. There are no refunds once acknowledgment and payment information has been made. I agree to come in for testing and will not be issued any refunds for any reason whatsoever once I have agreed to these terms.
I voluntarily: Authorize and direct my healthcare provider of Milltown Pharmacy to use or disclose my health information during the term of this authorization to any Physician, State or Federal Board or Agency, or Insurance Company, as required, for the purpose of treatment, payment, or other healthcare operation.
Further, I hereby given my consent: To the healthcare provider of Milltown Pharmacy , as applicable (each an "applicable Provider"), to administer the COVID-19 test(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving a COVID-19 test(s). I understand the risks and benefits associated with the above COVID-19 test(s) and have received, read, and/or had explained to me the information pertaining to the COVID test(s) I have selected and all of my questions have been answered by a Milltown Pharmacy staff member to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the COVID test(s) listed above.

TOTAL COST

USD Description

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date

Month Day Year
Date
Total Price (HIDDEN)
Should be Empty:

On March 22, 2022 at 11:59 pm ET, the HRSA COVID-19 Uninsured Program will stop accepting claims for testing and treatment due to a lack of sufficient funds

COVID-19 Testing

Please remember to bring in a photo ID and Insurance Card when you come in for your test.

On March 22, 2022 at 11:59 pm ET, the HRSA COVID-19 Uninsured Program will stop accepting claims for testing and treatment due to a lack of sufficient funds.