Medicare & Covid-Test Order Form

All Medicare Holders Are Eligible For COVID-19 tests

Fist Name

Last Name

Date of Birth

Gender

Male

Female

HICN Medicare Number

Have you received any other Covid-19 rapid tests through your Medicare benefits within this calendar month? *

Yes

Shipping Address

Apartment/Suite no.

City

State

Zip

Medicare Eligibility: I have validated that the patient is eligible to receive these tests

Phone Number

Preferred Method Of Communication

Phone

SMS text

Would you like to enroll in monthly refills? *

Yes

Recording URL

Jornaya or Trusted Form