Please read the following information and sign below:
1. I understand that Pineville Pharmacy will submit a claim to my insurance plan in order to receive (8) Covid-19 antigen at-home test kits at no cost to me. I would also like to receive PCR test if itis covered by insurance.
2. I understand that not all insurance plans provide coverage for the Covid-19 antigen at-home test kits.
3.Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results and my medical care. I agree I will seek medical advice, care, and treatment from my medical provider or other health care entity if have questions or concerns, if I develop symptoms of COVID-19, or if my condition
4. I understand it is my responsibility to inform my health care provider of a positive test result, and that a copy will not be sent to my health care provider for me.
5.I understand that my antigen test will not be performed by a healthcare provider at Pineville Pharmacy. The test will be performed by myself, and my result will be available in 15 minutes. If the result is positive, it may need to be confirmed with a PCR test.
6. The tests requested above are for personal use for the indicated patient(s)
7. These tests are not for employer or travel purposes.
8. I agree not to resale the tests provided under this covered benefit. 9. I allow Pineville Pharmacy to submit a claim to my insurance to receive (8) free COVID- 19 antigen at-home test kits.