Medicare Covered COVID-19 Tests

Medicare Covered COVID-19 Tests

Please send and complete this form for each covered member with Medicare. Eight (8) Flow Flex "at home" COVID-19 Tests will be directly delivered to you BY MAIL in 3-5 business days, at no cost to you. Please select the option to auto-mail your tests each month. ** This program has NO out of pocket expense to you. **
Referral

Are you filling this form out for yourself or someone else that is a Medicare member? *

Myself Someone Else
Would you like 8 Medicare-covered (no out of pocket cost to you) COVID-19 tests sent to you just one time or 8 tests per month?
There is ** no extra cost to you ** if you select to be sent 8 tests per month. Simply email us at support@TestHere.com to stop your monthly shipments at any time. *

8 Tests Per Month Just One Time

Relationship to Medicare Member *

Spouse or Partner Parent or Legal Guardian Son or Daughter Other Relative Attorney Estate Representative Other
A legal representative (sometimes called an authorized representative) is someone making decisions for and acting on someone else's behalf. In order to sign this form on behalf of someone else, you must be able to prove that you are a legal representative acting on their behalf, IF REQUESTED. Examples of proof of legal representation are: Appointment of Representative Appointment (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1696.pdf) of Representative; Advance directive; Conservatorship documents; Other legal representative contracts; Situations where you are not a legal representative; If you are assisting the participant in filling out in their presence, and submitting the form together, proof of legal representation is not needed. If the participant is under the age of 18, and you are their parent or legal guardian, proof of legal representation may not be needed.
Please check "I AGREE" Below to Continue. *

I AGREE

Required Information for Member

Please fill out all required fields below with your Medicare member information.
Please enter the member's FIRST & LAST NAME. *

First Name Last Name
Please enter your EMAIL ADDRESS. *
example@example.com
Please enter the member's DATE OF BIRTH below. *

Month Day Year
Date
Please enter your PHONE NUMBER below. *
Please Use this Format: ###-###-####
Please enter your Medicare MAILING ADDRESS below.

This is where your tests will be sent. This should match the address Medicare has on file for you.
Mailing Address 1 *
Mailing Address 2
City *
State *
Zip Code *

Medicare Member Insurance Information

Please fill out all fields below.
Full Name of Subscriber *
Exactly as it appears on your Member ID card.
Medicare B Member ID *
You can find your Member ID on your ID card or in your enrollment materials. Please double-check you entered it correctly.
Medicare Program Name (optional)
Exactly as it appears on your Member ID card.
BIN # (optional)
You can find your BIN on your ID card.
PCN # (optional)
You can find your PCN on your ID card.
Rx Group/Group ID # (optional)
You can find this on your ID card.
Please Upload the Front & Back of your Medicare B Card. *

Cancel of
Should be Empty:

Would you like 8 Medicare-covered (no out of pocket cost to you) COVID-19 tests sent to you just one time or 8 tests per month?