Please read this form in its entirety. This form is HIPAA compliant.

This form is an official request for COVID-19 at-home tests to be provided by Village Apothecary in Woodstock, NY. We currently stock FlowFlex tests that expire 11-23.

Please note:

• Some insurances may not participate in this program. Medicare B and D do!
• The home test we stock may not be covered by your specific plan.  Optum plans must go to Rite aid or Walmart for their tests.
• Many plans have limitations, such as 8 tests (or less) per 30 day period per person

Please especially note:

• A request for COVID-19 at home tests does NOT constitute an official guarantee of receipt of tests

PLEASE SUBMIT ONE REQUEST FOR EACH MEMBER OF YOUR HOUSEHOLD THAT IS COVERED BY YOUR INSURANCE.

 

We will process your order for the next business day.

 

We will contact you once your order is complete.

1. Enter Your Demographic Information

NAME: When entering your name, enter your LEGAL name and do NOT write middle initials. PLEASE write any suffix (Jr, III).

Address Information

ATTENTION: Please enter the address that is associated with your insurance (usually a HOME address).

If you are an international student, please use your LOCAL (i.e. school) address.

Other Demographic Information: 

For GENDER, please enter the sex at birth. These options are set by the NYS DOH, not Village Apothecary.

Required Documentation

In an attempt to reduce paper waste, all legally required documents must be downloaded here.

REQUIRED DOCUMENTS: 

Please click to download the EUA for the tests we have available (you may receive one of the following):

• Flowflex COVID-19 Antigen Home Test

Click here for the FlowFlex expiration date extensions from the FDA

All Patients

Click this to download the Notice of Privacy Practices

I understand the benefits and risks of the COVID-19 tests as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.

I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

I certify that I have received, read, and understand the Emergency Use Authorization.

I certifty that I have received the Notice of Privacy Practices.

I am requesting 8 (or third party allowable quantity) of At-Home COVID-19 tests for personal use.

Please type your full name in the box below. Your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge.

You understand that although the tests are no cost to eligible patients, your insurance status will be asked, and if applicable, pharmacy benefits insurance information AND/OR identification numbers such as State IDs or SSN will be collected or requested.

All information is confidential and is accessed only via a secure, encrypted interface.