• OTC COVID ORDER FORM

    Please check our Q/A: https://123escolab.com//COVIDHOMEQA
  • Patient's Information

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  • 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.

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  • 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

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