[No Cost] At-home Antigen COVID-19 Test

1
Select quantity* This field is required.Insurnace plans cover up to 8 tests per person per calendar month
Please Select
Please Select
2 tests
4 tests
6 tests
8 tests
Select Quantity
2
Patient Name* This field is required.
Patient First Name
Patient Last Name
3
Patient Gender* This field is required.
Male
Female
Other
4
Patient Date Of Birth* This field is required.
Date
Month
Day
Year
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.We'll use the phone number below to process the order for the patient. We won't contact the patient until we obtain their consent.
Please enter a valid phone number.
7
Where would you like the tests?* This field is required.
Mail - Please mail them to my mailing address
Pick Up - I will pick them up from the pharmacy
8
If you would like to request tests for my spouse/significant other who is also 65+ 1) First & Last Name (s) and 2) Date of Birth (s) herein and 3) Medicare B #. 8 tests will be provided per person.If none, click next
Huge
Large
Normal
Small
Ok
Ok
9
Would you like to receive 8 tests each month?* This field is required.We will reach out to you to confirm if you would like us to provide you with 8 additional tests. If at any time you do not need more tests, you may also email us at camdenrxde@gmail.com to inform our team accordingly.
YESNO
10
Does the patient have insurance?* This field is required.
Prescription insurance
Medicare Part B
Both
11
Primary insurance information* This field is required.
Name of Insurance provider
Member/Recipient ID number
Group number
Rx PCN
Rx BIN
12
Please enter the Medicare Number for the next promt
13
Medicare Number* This field is required.
14
Signature* This field is required.I acknowledge I am allowed to get 8 tests per month from Medicare without any cost to me directly. I allow Camden Pharmacy to bill Medicare B to cover the cost of the at-home rapid covid test kits. By signing below, the patient is attesting: The tests are for personal use for indicated patient(s) on the form, the tests are not for employer or travel purposes, the tests are not for children < 2 years old, the patient will not resell the tests provided under their benefit, the cost of the tests is not being covered by any other source. The patient has not requested OTC COVID-19 tests from any other provider in the current calendar month.
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