Requests for at-home COVID-19 test kits via insurance
Local residents only, please
Please help us by agreeing to the statements below. Please read and click each box.
Orders are fulfilled depending on stock and insurance. Please do not call us regarding at-home COVID-19 tests provided by insurance.
Due to staffing, we are unable to answer calls, emails, messages about the status of the order or provide assistance with online forms.
If you are able to get tests elsewhere after filling out this form, you do not need to notify us. Your insurance will let us know not to fill it.
Once your order is filled, you will receive a text message or a call. We will hold your order for 14 days.
Orders cannot be mailed.
Please choose a test kit.
FlowFlex Ag Home Test
Number of Kits Requested
Most insurances will cover between 4 and 8 tests every 30 days
Date of Birth
Patients under the age of 18 must be accompanied by parent or guardian.
If you wish to receive texts.
If you wish to receive calls.
Gender (according to insurance)
Type of Insurance (primary only)
Insurance Information (or provide photo of card below)
Photo of Insurance Card (or provide information above)
I request the at-home COVID-19 test kits to be given to me or to the person named above, a minor for whom I have legal custody and I am authorized to sign this consent form.
I understand that I will be receiving the at-home COVID-19 test(s) at no cost to me. If insured, I attest that I will provide my insurance card(s) at the time of pickup. I am authorizing the pharmacy to bill my insurance on my behalf for the test kits.
I understand that PHARMACY may be required to or may voluntarily disclose my health information to my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that PHARMACY will use and disclose my health information as set forth in the PHARMACY Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy).
I acknowledge that I have read this release form prior to signing it and that I understand its contents. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless & their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the At Home COVID-19 tests listed above.
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