Medicare At Home Test Request

Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Medicare Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Number of Tests Requested (max 8)
I hereby certify that the above information is correct and that I have requested and am receiving at-home rapid antigen tests from Downtown Pharmacy. I understand that I will not have any out of pocket costs for receiving these tests and I authorize Downtown Pharmacy to seek reimbursement from Medicare.
Signature

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Today's Date

MonthDayYear
Date
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