At-Home COVID-19 Test Request
For Medicare and Medicaid Members
Who is requesting the test
Patient Name
*
First Name
Last Name
Patient Birth Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Patient Medicare Number (if 65+) or Medicaid Insurance ID (if under 65). If unknown, please use SSN.
*
Number of Tests Requesting -- (Up to 8 tests per month are free)
Please Select
1
2
3
4
5
6
7
8
Additional Patient Information (i.e. deliver to back door, caregiver information)
Your Name
First Name
Last Name
Your Office
Email
example@example.com
Submit
Should be Empty: