Free At Home Covid Tests
Take a free COVID-19 home test! Many insurance plans will cover COVID-19 home tests at no cost to you. Once you fill out the form below, we’ll prepare your order as timely as possible and contact you by phone. Quantities of tests distributed are subject to insurance and inventory limitations. Typical monthly allowed amounts allowed are: 8 home tests for Medicare and commercial patients, and 2 tests for Missouri Medicaid patients. Tests can be ordered monthly. Contact us with any questions at (417) 451-9501 or info@mitchelldrug.com
Full Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Phone Number
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Do you have any known medication allergies?
*
Yes
No
Please list them.
Do you live in Missouri? (Must be a Missouri Resident)
*
Yes
What is your preferred delivery method?
*
Store pick up (Boulevard store)
Shipping
If these tests are not covered by your insurance plan, how many would you like to pay for?
*
1 for $18
2 for $30
3 for $42
4 for $55
If insurance does not cover covid tests, I don't want any (you won't hear from us)
We are happy to offer free delivery for home tests to places of business and facilities with multiple orders. Please let us know if you'd like this accommodation (May ignore if not applicable) (Yes/No)
I have read the attestation below and am requesting these covid tests. (Type name)
*
Name
Insurance information
Insurance information is required for free at home covid tests. If we have your insurance on file already, skip this section. If we don't have your insurance on file, please answer the following questions:
Do we have your updated insurance information at our pharmacy?
Yes
No
Insurance BIN:
Insurance PCN:
Insurance Cardholder ID:
Insurance group #:
Do you have Medicare?
Yes
No
Medicare Part B (Red white and blue card) number:
Submit
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