PATIENT REQUEST
AT HOME OTC COVID-19 TEST
Date Requested
*
-
Month
-
Day
Year
Date
Method of Request
*
Online
Phone
Person Requesting
*
Self
Facility
Facility Name
*
Facility Personnel Name
*
First Name
Last Name
Patient's Name
*
First Name
Last Name
RESIDENT LIST (Add rows if needed)
*
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Medicare Number (No Dashes)
*
Upload your Medicare Card Image (Blue White card)
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Quantity Requested
*
Please Select
8
Patient approves refills for additional 2 months after this order?
*
Yes
No
Attestation
I authorize Bio Serve Inc. to provide the above listed OTC COVID-19 tests and attest to the following: To bill my insurance respectively. The tests requested above are for personal use for the indicated patient(s). These tests are not for employer or travel purposes. I agree to not resale the tests provided under this covered benefit. I authorize Bio Serve Inc. to automatically refill my request for additional 2 months after I receive this order (8 tests). The cost of these tests is not being covered by any other source.
Signature of patient (or legal representative) or Caretaker or authorized facility Rep
*
Clear
Patient/s understands and consents to all disclosures and conditions for using this program?
*
Yes
Lab Agent Name (If phone order)
Tracking Number (for internal use)
Submit
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