• Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825

    Covid Home Testing Kit Request

    Medicare & Insurance ONLY Patients

    rev:07/06/2022 HIPAA Compliant ver 2.3

     

  •  ***** Important *****

    If you have not filled a prescription or had a vaccination at Lopez Island Pharmacy within the past 2 years, please go to back to LopezIslandPharmacy.com  and fill out a online new patient intake form, either do this before doing this form or after you have finished this form.

    Insurance or Medicare Part B will cover Covid at home testing at no charge to you.  You can get 8 tests per 30 days.  In some cases you will receive a (1 or 2) 2 pack of tests so you could get a maximum of 8 individual tests in 30 days.  

    Due to availability issues we will only provide you with (1 or 2) boxes of 2 tests at this time.  This is on a first come basis only once all forms are completed.  The request will expire after 48 hours.  You may order more during the month, again subject to availabity. 

    You must pickup the test you requested within 48 hours.  If someone else picks up the tests for you please call ahead to tell us who is picking up.  If you suspect you are positive, or have been exposed - PLEASE let us know and we will bring your tests out to the parking lot for you.

    You will receive a phone call or a Text Message that your tests are ready to be picked up, please wait for the call, it will be a generic message that you have an order ready at the pharmacy.

    If you do not have Medicare or insurance you can get free tests by ordering from the Federal or State governmental website.

     

  • Kaiser Insurance will NOT cover these free test kits.

  • If you have not or are unsure that you have filled a prescription or a vaccination before at Lopez Island Pharmacy.  Please fill out the new patient form on our website or the below link, without this form we cannot bill your insurance.  

    https://hipaa.jotform.com/202091258277153


  •  - -
    Pick a Date
  •  -
  •  -

  • If someone else picks up the tests for you please call ahead to tell us who is picking up. If you suspect you are positive, or have been exposed - PLEASE let us know and we will bring your tests out to the parking lot for you.

  • Please enter your EMail and then press "Next" and on the last page press "Submit"

  • If you have not had a prescription filled at Lopez Island Pharmacy, or received a vaccination within the past 2 years we will need a new patient form completed.  This form is on our web page or at this link.

    We will not be able to honor a request for testing kits if you have NOT filled out a new patient form.

     

    After hitting the "Submit" Button you will get a green check mark notifiying you the form has been sent to us. Then wait for the automated call/text notification that your test is ready to be picked up.

  • If you don't have Medicare or Insurance we have testing kits for purchase, if you still are unsure please call and speak with us, 360-468-2616

  • Attestion: I have request Lopez Island Pharmacy to provide the requested COVID-19 Tests and attest the following:

    • The tests requested are for personal use for the individual requesting them.
    • These test are not for employer or travel purposes.
    • I agree not to resale the tests provided under this covered benefit.
    • The cost of these test is not being covered by any other source.
    • I have not requested Covid-19 tests from another provider in the current calendar month.
  • Clear
  • Should be Empty: