At-HOME COVID-19 TEST(S) CONSENT AND RELEASE FORM

OTC AT-HOME COVID-19 TESTS ORDER CONSENT FORM
VALLEY MEDICAL PHARMACY

630 Main Street, Brawley, CA 92227

Phone Number: (760) 344-6303

Fax Number:(760)344-6321
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
PHARMACY INSURANCE INFORMATION: BIN# PCN# RxGroup# ID#*
I authorize Valley Medical Pharmacy to bill my insurance for * (enter # of test(s) being ordered - Max 4 for 30 days).
Please Check All*

I understand that tests are non-refundable, and non-returnable.I understand that tests are for the individual or covered dependent use only.I attest tests will not be used to satisfy employment requirement, are not used for resale, and the cost of the test is not being covered by any source other than sponsor.
Reason For Requesting Test*

I was recently exposed to someone with Covid-19. (Z20.822)I had tested positive for Covid recently, and would like to verify my progress to negative test result. (U07.1)
Choose one*

I will pick up my AT-HOME COVID-19 TESTS at Valley Medical PharmacyI want my AT-HOME COVID-19 TESTS to be delivered by the Pharmacy delivery driver (Brawley, Westmorland, Calipatria, Niland and Bombay Beach)I want my AT-HOME COVID-19 TESTS to be delivered by the US Postal Service

Please Provide Address for US Postal Service Delivery
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of billing of at home covid test(s) requested. I understand that it is not possible to predict all possible side effects or complications associated with receiving test(s) On behalf of myself, my heirs and personal representatives. I hereby release and hold harmless Valley Medical Pharmacy, 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 test(s) listed above. I authorize Valley Medical Pharmacy as applicable, to release my medical or other information to my healthcare professionals,Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf Valley Medical Pharmacy as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including co-pays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, upon receipt of such invoice.
Patient Signature*

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Pharmacist Signature

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Should be Empty:

OTC AT-HOME COVID-19 TESTS ORDER CONSENT FORM