AT HOME COVID TEST ORDER FORM

AT HOME COVID TEST ORDER FORM

Free delivery within 5 miles of the store. Zero Out-Of-Pocket costs for many insurances. Not all insurances participate.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
How many tests would you like to order? Max 8/month on Medicare and most insurances*
PLEASE INCLUDE THE FOLLOWING INFORMATION FOR BILLING INSURANCEINSURANCE CARRIER*ID#MEDICARE OR MEMBER NUMBER* GROUP NUMBER (IF NONE LEAVE BLANK)
I ACKNOWLEDGE THAT ON MY BEHALF MEDICAP PHARMACY 8396 WILL BILL MEDICARE PART B OR MY PRIVATE INSURANCE FOR UP TO 8 COVID TESTS PER CALENDAR MONTH AND THAT NO OTHER ENTITY HAS DONE SO ON MY BEHALF.*
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