OTC COVID Test Request Form

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.
Which OTC COVID Test does the patient need?*

Flowflex (1 test per pack) 8 tests total
How would you like to get your tests?

In-store Pickup (Select Pickup Date and Time Below)
Please Select a date and time to Pick Up your OTC COVID-19 Tests*

Patient Demographic Information
Patient Name*

FirstNameLastName
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

AddressOne

AddressTwo

CityStateCode

Zip
Patient Gender: (M: Male and F: Female)*

MF
Cell Phone Number: (Please double check for accuracy)*
Please enter a valid phone number.
Primary Phone Number: (Please double check for accuracy)*
Please enter a valid phone number. Only enter the numbers no ( ) or dashes
Patient Email*
example@example.com

Does the Patient have Prescription Insurance?*

YESNO (uninsured)
If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)

I am an existing Tarrytown Pharmacy patient and my insurance is up to date in the systemMedicare Part A/B (Red, White, & Blue Card for patients over the age 65)Prescription Insurance (Coverage for medications at a pharmacy)
Please Enter Medicare Part B ID# (red, white, and blue card for patients over 65)
*if you are not over 65 or do not have part B, enter "n/a".
Rx Bin#
This information is found on your PRESCRIPTION insurance card.
Rx PCN
This information is found on your PRESCRIPTION insurance card.
Rx GROUP ID
This information is found on your PRESCRIPTION insurance card.
Member ID
This information is found on your PRESCRIPTION insurance card.

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
Date of Form Completion*

MonthDayYear
Date
Consent Signature of patient or authorized representative*

Clear
Should be Empty:

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