Language
English (US)
Request for At Home COVID-19 Test
Date Requested
*
/
Month
/
Day
Year
Date
Method of Request
*
Online
Patient Name (Last Name, First Name)
*
Beneficiary DOB
*
MM/DD/YYYY
Person Requesting
Please Select
Self
Patient Caretaker
Caretaker's Name
First Name
Last Name
Facilty Number
*
Please enter a valid phone number.
Email
example@example.com
Quantity Requested
*
Please Select
8
Order Type
*
Please Select
Delivery
Insurance Name
Rx Bin#
Rx PCN#
Rx Group#
ID#
Take A Picture of Insurance Card (Front Side)
Take A Picture of Insurance Card (Back Side)
Attestation
I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following: The tests requested above are for personal use for the indicated patient(s) These tests are not for employer or travel purposes I agree to not resale the tests provided under this covered benefit The cost of these tests is not being covered by any other source
Signature of patient (or legal representative)
*
Clear
Name
Last Name
First Name
Date
/
Month
/
Day
Year
Pharmacy Only Claim Info
Name of OTC COVID-19 Test being supplied
Pharmacist on Duty
Submit
Should be Empty: