• Monoclonal Antibody Treatment for Covid-19 Interest Form

    • Instructions: Complete this form in its entirety to the best of your knowledge. If you don’t know the answers to some of these questions, please leave it blank or write "NA"
    • Please complete form online along with a copy of positive COVID-19 result AND a copy of insurance card if available.
    • For uninsured patients, the monoclonal antibody treatment is FREE and paid by the United States Health Resources & Services Administration's COVID-19 Program.
    • Once the completed paperwork has been received, a pharmacy representative will contact the patient to coordinate services as soon as possible.
    • Please note: There is always the possibility that a patient's clinical condition may change during the time between referral and injection appointment, to the point where mAb therapy may no longer be indicated for the patient. If a patient has clinically declined by the time of scheduled appointment, we will refer them to a higher level of care, if needed, without administering mAb.
    • Required Documentations  
    • Browse Files
      Drag and drop files here
      Choose a file
      Cancel of
    • Doctor Information  
    • Patient Information  
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    •  -  -
      Pick a Date
    • Clear
    •  
    • Should be Empty: