OTC COVID ORDER FORM

OTC COVID ORDER FORM

Please check our Q/A: https://123escolab.com//COVIDHOMEQA
Patient's Information
Are you an existing or new patient?

Existing ESCO Customer?New ESCO Customer?

1E. Full Name*

First NameLast Name
2E. Date of Birth*

MonthDayYear
Date
3E. Phone Number*
Please enter a valid phone number.
1N. Full Name*

First NameLast Name
2N. Date of Birth

MonthDayYear
Date
3N. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4N. Gender?*

MaleFemaleOther
5N. Phone Number*
Please enter a valid phone number.
6N. Email*
example@example.com
OTC SELECTION*

OTC COVID-19 TEST
7N. Do you want to add additional people?

YesNo
Additional People [Max 10]
RX Insurance and Medical Insurance examples
If you have no insurance, upload
a) foreign passport, b) foreign id, or c) non NY resident ID

If you have no insurance and ARE FROM NY, upload
d) social security and social security ID

If you have insurance:

For the RX Insurance card, they generally have the following information: RX BIN#, RX PCN#, RX GROUP#, RX MEMBER ID#.

You can see some examples at: https://escopharmacy.nyc/pharmacy/sample/rxinsuranceexamples.

For Medical Insurance, you can find example at the link here:
https://escopharmacy.nyc/pharmacy/sample/medical-insurance-examples.
Please upload your pharmacy insurance card here (Front and Back)*

Cancelof
Form Attestment
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 not to 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
Should be Empty:

OTC COVID ORDER FORM

Patient's Information

RX Insurance and Medical Insurance examples

Form Attestment