Covid-19 Home Antigen Test Request Form

COVID-19 Home Antigen Request Form

Medicare and Most insurance companies will allow Covid-19 home antigen test to be billed out and provided FREE to you. Maggy Pharmacy is a participating pharmacy in the Medicare Over-The-Counter (OTC) tests initiative. Maggy Pharmacy will bill Medicare or Private Insurance on your behalf for Covid-19 Home Antigen Tests. Medicare covers a Max of 8 Home Tests every 30 days if needed. You may request less. Most private insurance companies, but not all, will cover Covid-19 Home Antigen tests. Quantities allowed may vary.
Please use this form to fill out a request for FREE Covid-19 Home Antigen Tests. This form will allow us to bill Medicare or your prescription insurance company on your behalf. Maggy Pharmacy will notify you if more information is needed or what is allowed by your insurance.

Most insurances will cover the costs of the Home Antigent Tests with NO out of pocket costs. Some insurances may not cover these tests. Maggy Pharmacy will let you know if your insurace does not cover the home test you requested.

If you are uninsured the Covid-19 Home Antigen Tests will not be covered through our pharmacy. You may have other options in the community to receive free tests through local towns, fire departments, and governemnt agencies.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth:*

MonthDayYear
DOB
Gender:*
Phone Number*
Please enter a valid phone number.
Is the Phone number a:*
Please Select the Number of Tests Requested:*
Medicare Max 8 Tests/30 days
Do you have Medicare or Private Insurance*
Please Enter your Medicare ID Number or Private Insurance ID on Rx Card*
Example: MQ1122CC1
Please Enter BIN Number on Rx Card: (If available)
Bin Number (Example 04336)
Please Enter Rx Group Number on Rx Card: (If available)
Rx Group (Example NYSTATE)
Please Enter PCN Number on Rx Card: (If available)
PCN Number (Example MEDDADV)
Medicare Beneficiary - I assign the right and responsibility to Maggy Pharmacy Inc to bill on my behalf and accept payment for Medicare for the Home Covid-19 Antigen Tests that I have requested.*
Private Insurance - I assign the right and responsibility to Maggy Pharmacy Inc to bill on my behalf and accept payment for the Home Covid-19 Tests that I have requested.*
I permit Maggy Pharmacy Inc to release and collect my health information, and other information, as required (and as permitted by the HIPAA Regulations) from my health care provider Medicare or my private insurance.

I understand this form will be maintained and kept on file and made available to Medicare or my insurance representatives if requested.
Signature Required:*

Clear
Name of Person requesting Test:*

First NameLast Name
Date Request was Made:*

MonthDayYear
Date
Should be Empty:

COVID-19 Home Antigen Request Form