At-Home COVID Test Request Form

COVID-19 At-Home Test - Order Request Form

At-Home Tests will be billed to your insurance at no cost to you - Subject to insurance plan preferred products and limits **Limit 8 per person every 30 days, WHILE SUPPLIES LAST*
**Please note, we cannot bill Medicare for at-home COVID-19 tests at this time, if you are insured through Medicare you are not eligible for this offer**
I verify that the At-Home COVID tests being requested are to be used for personal use; they will not be used for employment purposes or resale.*

Yes, I certify that the above statement is trueNo, I do not certify that the above statement is true
COVID tests billed to an individual's private/commercial insurance are only approved for personal use - use beyond this is prohibited. Tests for purposes beyond personal use must be purchased outright and cannot be billed to insurance.
Where would you like to pick-up your at-home tests? Choose from one of our four Granite Pharmacy locations across Montana.*

Granite Pharmacy FrenchtownGranite Pharmacy LibbyGranite Pharmacy MissoulaGranite Pharmacy Philipsburg
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
This number will be used to send a text message when your tests are available for pickup at Granite Pharmacy
Provide your insurance information:

As displayed on your pharmacy benefit card
BIN or RxBIN:*
ID number:*
RxGroup or RxGRP:*
PCN or RxPCN:*
Medicare Beneficiary ID (from red/white/blue card) - if applicable:
Are there any other members of your family, that are COVERED DEPENDENTS on your insurance plan, that you would like to also receive at-home COVID tests?*

YesNo, just me
Provider their name(s) and birthdate(s) to receive tests for them as well.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add additional covered dependents?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add additional covered dependents?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add additional covered dependents?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add additional covered dependents?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Add additional covered dependents?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
How many At-Home COVID-19 tests would you like? Max of 8 (**subject to individual insurance limits**)*
Should be Empty:

COVID-19 At-Home Test - Order Request Form

Provide your insurance information: