Medicare & Commercially-Insured Patient Request & Attestation for OTC COVID-19 Test Billing
Person Requesting
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date Requested
*
/
Month
/
Day
Year
Date
How many patients are you requesting for? (Please note a separate form will need to be completed for anyone that is residing at a different address?)
*
Please Select
1
2
3
4
5
Patient 1
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Quantity Requested
*
Please Select
1
2
3
4
5
6
7
8
Relationship to Patient
*
Ex: Self
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does this patient have Medicare Part B?
YES
NO
What is this Patient's MEDICARE number?
Patient 2
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Quantity Requested
*
Please Select
1
2
3
4
5
6
7
8
Relationship to Patient
*
Ex: Self
Does this patient have Medicare Part B?
YES
NO
What is this Patient's MEDICARE number?
Patient 3
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Quantity Requested
*
Please Select
1
2
3
4
5
6
7
8
Relationship to Patient
*
Ex: Self
Does this patient have Medicare Part B?
YES
NO
What is this Patient's MEDICARE number?
Patient 4
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Quantity Requested
*
Please Select
1
2
3
4
5
6
7
8
Relationship to Patient
*
Ex: Self
Does this patient have Medicare Part B?
YES
NO
What is this Patient's MEDICARE number?
Patient 5
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Quantity Requested
*
Please Select
1
2
3
4
5
6
7
8
Relationship to Patient
*
Ex: Self
Does this patient have Medicare Part B?
YES
NO
What is this Patient's MEDICARE number?
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
*
I have requested the pharmacy to provide the listed OTC COVID-19 tests on this form and attest to the statements above.
Signature of Patient (or Legal Representative)
*
Clear
Sig: Test as directed per manufacturer and CDC guidance
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