IN-NETWORK AUTHORIZED PROVIDER
COVID TEST DELIVERY PROGRAM
FINAL STEP (Step 2 of 2)
Additional Info
Gender:
Please Select
Male
Female
Prefer not to Say
Marital
Status:
Please Select
Single
Married
Divorced
Widowed
Residence
Type:
Own
Rent
Live with Family
Retirement Community
Other
Date of Birth:
Military Veteran?
No
Yes
Order Preference:
Send 8 Tests monthly
Single 8 Test shipment
Medicare Required Information:
Medicare Number:
(11 Characters, no Dashes)
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Reason for
Testing:
Please Select
Experiencing symptoms
Exposed to someone with Covid-19
Live or work in congregate setting
Attend School / Children attending School
High Risk or Underlying Conditions
Age 65 or Older
Been exposed to a large group of people
Asked to get tested by healthcare professional
Asked to get tested by a contact investigator
Asked to get tested by a public health department
Other (Please enter Notes)
Notes
(if 'Other' Reason):
Why you should have tests at home, just like you would Band-Aids:
> If you’re going to a Doctor or into an Office <
> If you’re Traveling (Planes, Trains & Automobiles) <
> If you’re participating in Athletics, Clubs and Social Activities <
> Before you visit others that are elderly or high-risk <
> Before Business Trips & Conferences <
> Before Church and Family Gatherings <
> Before going to a Restaurant or other Outing <
> Carpools, Rideshares and Buses <
> Required for many Sporting Events and Concerts <
Don’t make an expensive and inconvenient trip to the Doctor or Clinic!
Get your Insurance Authorized allotment of COVID tests completely Free to You today!
