At-Home COVID-19 Tests

Request At-Home COVID-19 Tests

Fill out the information below so that we can submit a request to your insurance for your at-home COVID-19 tests. If you are a Medicare or Medicaid member, please contact the pharmacy at (682) 708-3499 for assistance.
How many at-home tests do you need? *
Minimum order of 2 tests. Depending on the brand, you will receive 1 or 2 tests per pack.
Patient Information

Please fill in the information for the person who the tests are for. You must submit a separate request for each person on your insurance plan.
Name*

First NameLast Name
Address*

Street Address

Unit, Apartment, etc. (Optional)

CityState

Zip Code
Phone*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Sex assigned at birth*

FemaleMale
Contact Information

We will text and email you about your order status. Standard data rates may apply.
Email
example@example.com
Mobile Phone
We will text and email you about your order status. Standard data rates may apply.

Request At-Home COVID-19 Tests