OVER-THE-COUNTER COVID TEST REQUEST FORM
FULL LEGAL NAME
*
FIRST
LAST
PHONE NUMBER
*
-
AREA CODE
PHONE NUMBER
EMAIL ADDRESS
*
EXAMPLE@EXAMPLE.COM
DATE OF BIRTH
*
/
Month
/
Day
Year
ADDRESS
*
STREET ADDRESS
STREET ADDRESS LINE 2
CITY
STATE
ZIP CODE
Date of Birth:
*
MM/DD/YYYY
MEDICAL INSURANCE INFORMATION
What type of medical insurance do you have?
*
Medicare Part B
Medicaid
Commercial Insurance (ex. Aetna, Cigna, United Healthcare)
Uninsured
MEDICARE PART B RECIPIENTS:
(THIS SECTION ONLY APPLIES TO MEDICARE PART B PATIENTS)
ENTER YOUR NAME AS IT APPEARS ON YOUR RED, WHITE AND BLUE MEDICARE CARD
First Name
Last Name
ENTER YOUR MEDICARE BENEFICIARY IDENTIFIER
THIS IS YOUR 11-CHARACTER COMBINATION OF NUMBERS & LETTERS WHICH IS YOUR UNIQUE IDENTIFIER MEDICARE USES. AN EXAMPLE OF THE CARD YOU WILL OBTAIN THIS 11-CHARACTER MEDICARE NUMBER FROM AND WHERE IT IS LOCATED IS SHOWN IN THE EXAMPLE BELOW
Example:
I request DeliveRxd Pharmacy to deliver (at no cost) 8 Covid-19 OTC rapid self-tests to the address I've entered on this form. I authorize DeliveRxd Pharmacy to bill my insurance company on my behalf with the understanding that my insurance company covers 100% of the cost of these tests and DeliveRxd Pharmacy will also deliver them to me for free! I will expect my OTC Covid self-tests in 7-10 business days.
*
Yes
Patient Signature (sign name)
*
Clear
Today’s Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: