Attestation for
OTC COVID-19 Test Billing
Documentation of Request
METHOD OF REQUEST
PHONE IN
IN PERSON
Electronic
OTHER:
Patient Name
DOB
Address
Address
Street Address Line 2
City, State Zip
State / Province
Postal / Zip Code
Phone Number
Medicare Number
Insurance Card
DATE REQUESTED
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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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