• Free at-home Covid-19 Test Request Documentation

    *All fields are required for your order to be processed.
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    Pick a Date
  • For additional family members, submit this form for each person.

     

    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/person.
    • 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 understand if my insurance does not cover the tests, or if any information I have provided is inaccurate, I will not receive any tests and I will not be contacted informing me so.

  • ----------------------Pharmacy Only Claim Information-------------------------

    Name of OTC COVID-19 Test being supplied: Flow Flex
    Sig: Test as directed per manufacturer and CDC guidance
    No Refills
    Pharmacist on Duty: Timothy S. Burke

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