Covid Test Order Form

Free at-home Covid-19 Test Request Documentation

*All fields are required for your order to be processed.
Exact name on Insurance Card *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Take Photo of your insurance card showing BIN, PCN, GROUP and ID Number
Medicare Number if Applicable (Not Medicare Advantage Number)
Phone Number *
E-mail *
example@example.com
Home/Delivery Address *

Street Address

Street Address Line 2

City State

Zip Code
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
Should be Empty:

Free at-home Covid-19 Test Request Documentation