• Medicare & Commercially-Insured Patient Request & Attestation for OTC COVID-19 Test Billing

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  • Patient 1
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  • Patient 2
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  • Patient 3
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  • Patient 4
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  • Patient 5
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  • Attestation
    • The tests requested above are for personal use for the indicated patient(s)
    • These tests are not for employer or travel purposes
    • I agree not to resale the tests provided under this covered benefit
    • The cost of these tests is not being covered by any other source
    • I have not requested OTC COVID-19 tests from another provider in the current calendar month
  • Clear
  • Sig: Test as directed per manufacturer and CDC guidance

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  • Should be Empty: