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  • Request for At Home COVID-19 Test

    Request for At Home COVID-19 Test

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  • 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
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  • Pharmacy Only Claim Info

  • Should be Empty: