Monoclonal Antibody Treatment for Covid-19 Interest Form

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
Do you have Health Insurance? *
What is your insurance provider (insurance name) ? *
If you are insured, please type "NA"
Please submit the required document here (insurance card, a copy of positive COVID 19 result)

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Doctor Information
Primary Care Provider *
If you don't have a Primary Care Provider, write "N/A" in this field.
Organization *
If you don't have a Primary Care Provider, write "N/A" in this field.
Phone Number *
Please enter a valid phone number. If you don't know the phone number, type "410 000 0000"
Zip