Documentation of Request - Medical and Commercially-Insured Patient Request and Attestation for OTC COVID-19 Test Billing
Eight free rapid COVID test kits a month at no cost depending on your insurance. To receive your free tests, please provide the following information using this safe, secure portal.
Requested Method
Online
First Name
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Last Name
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Date Of Birth (MM/DD/YYYY)
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Gender
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F
M
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Address
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City
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State
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ZIP
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Cellphone Number
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Email
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Confirm Email
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Race
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American Indian or Alaska Native
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Native Hawaiian or Other Pacific Islander
Not Specified
Other
White
Ethnicity
** Please Select **
Hispanic or Latino
Not Hispanic or Latino
Unable to Report Due to Policy/Law
Unknown
Number Tests
8
I'm interested in receiving 8 free tests and agree to the conditions outline below:
ATTESTATION AND CONSENT
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
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 request that payment of authorized benefits under Medicare, Medi-Cal, or other commercial insured plan
that I am currently covered under be made on my behalf to El Camino Hospital Outpatient Pharmacy or its
affiliate for any product or service furnished to me under this request.
I consent that the pharmacy may message me via Text message or RxLocal app when my order is ready and mailed out
If you have any questions related to this program please contact by telephone at 650-988-8240, email:
outpatientpharmacy@elcaminohealth.org
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We are located at 2500 Grant Road Suite 1B20, Mountain View, CA 94040.
Please type your name below:
Signature
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Signature Date
11/21/2024
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Submit Order
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