I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following:
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The tests requested above are for personal use for the indicated patient
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I agree not to resell these tests provided under this covered benefit
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I have not requested OTC COVID-19 tests from another provider in the current calendar month under this covered benefit
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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