• Tarrytown Pharmacy Medicare/Insurance Patient Request for OTC COVID-19 Tests

    Please read below carefully and fill out the form to the best of your knowledge.
  • Patient Demographic Information

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  • Attestation, Consent, and Signature

  • 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
    • I agree not to resell these tests provided under this covered benefit
    • I have not requested OTC COVID-19 tests from another provider in the current calendar month under this covered benefit
    • I acknowledge that if these tests are not covered under my insurance then I will need to purchase them out of pocket if I desire, or request Tarrytown Pharmacy to cancel my order request
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