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Request at-home tests

Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required.

Do you carry health insurance?*

Yes

No

Note: This program only applies to those persons who carry health insurance

Do you want express of ground shipping?*

UPS Ground (7-10 Days) FREE

Express shipping & handling 2-3 day - $29.99

Note: If you order less than 8 kits shipping charges apply.

Tests

Minimum order of 2 tests. You will receive 2 tests per pack. Anything less than 8 tests will have a shipping charge applied.

Who are the tests for?

Insurers cover up to 8 at-home COVID-19 tests per person monthly. All fields are required.

Are you submitting the request for yourself of someone else?*

Myself

Someone else

Reason for Testing*

e.g. high-risk settings, possible symptoms, large gatherings with possible exposure.

Address Recognized by your Insurance Company*

First Name and Last on record with your Insurance Company must match exactly.

First Name Last Name

Date of birth*

Address*

Street Address Unit, apartment etc (optional) City State ZIP Code

This is the address that your insurance company has on record for you. Could be your address or possibly your spouse/parent's address.

Email address*

Mobile Number*

Preview Submission

Do you carry health insurance?
Do you want express of ground shipping?
Tests
Are you submitting the request for yourself of someone else?
Reason for Testing
First Name
Last Name
Date of birth (MM/DD/YYYY)
Address	, ,
Email address
Mobile Number

Sex assigned at birth*

Female

Male

Note: Required fields*

Insurance Carrier*

Insurance Number*

Insurance Group Number

*If applicable

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preview Submission

Do you carry health insurance?
Do you wont express of ground shipping?
Tests
Are you submitting the request for yourself of someone else?
Reason for Testing
First Name
Last Name
Date of birth (MM/DD/YYYY)
Address	, ,
Email address
Mobile Number
Sex assigned at birth
Insurance Carrier
Insurance Number
Insurance Group Number
Shipping Address	, ,

Add your insurance card image*

Accepted file types: jpg, jpeg, png, hvec, Max. file size: 256 MB.

Preview Submission

Do you carry health insurance?
Do you wont express of ground shipping?
Tests
Are you submitting the request for yourself of someone else?
Reason for Testing
First Name
Last Name
Date of birth (MM/DD/YYYY)
Sex assigned at birth
Insurance Carrier
Insurance Number
Insurance Group Number
Address	, ,
Email address
Mobile Number
Shipping Address	, ,
Your Insurance Card

Consent*

I agree to the privacy policy.

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