• Attestation for OTC COVID-19 Test Billing Documentation of Request

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  • Attestation:

    • I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following:
    • 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 #8 OTC COVID-19 Flow flex test. NDC: 82607-0660-26
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